Every finding on record at Focused Care at Summer Place

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 4 of 4 residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for pharmaceutical services. The facility did not ensure accurate dispensing of medications for Resident #1, Resident #2, Resident #3, and Resident #4. This failure could place residents at risk of not receiving therapeutic levels of medications ordered by their physician. Findings included: Resident #1Record review of a face sheet dated 06/10/26 indicated Resident #1 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included hypertension (a condition in which the force of the blood against the artery walls is too high), chronic embolism and thrombosis of the leg (formation of blood clots), constipation (infrequent bowel movements or difficulty passing stool), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), dry eyes (insufficient tear production), protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), anxiety disorder (persistent and excessive worry that interferes with daily activities), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and diabetic neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #1's BIMS was 07 out of 15 indicating she had severely impaired cognition. Record review of the care plan dated 07/29/26 indicated Resident #1's diagnoses were addressed and appropriate goals and interventions were in place including an intervention to administer medications as ordered. Record review of August 2026 physician orders for Resident #1 indicated the following:* an order dated 02/21/26 for amlodipine besylate (to treat high blood pressure) 5 mg give 1 tablet one time a day hold SBD< 110 and DBP < 60 for hypertension;* an order dated 06/13/26 for aspirin (used to help thin blood) chewable tablet 81 mg give 1 tablet one time a day related to chronic embolism and thrombosis of the leg;* an order dated 04/30/26 for docusate sodium (stool softener) 100 mg give 1 capsule one time a day for constipation;* an order dated 06/12/26 for glycolax powder (laxative) give 17 gram mix with4-8oz water and drink one time a day for constipation;* an order dated 07/06/26 for levofloxacin (antibiotic) 750 mg give 1 tablet one time [NAME] for possible UTI for 7 days until 07/15/26;* an order dated 06/23/26 for Lexapro (antidepressant) 10 mg give 1 tablet one time a day for major depressive disorder;* an order dated 04/01/26 for Metoprolol Succinate (to treat high blood pressure) Extended Release 50 mg give 1 tablet one time a day hold SBP< 110 and DBP< 60, pulse < 60 for hypertension;* an order dated 07/02/26 for artificial tears (for dry eyes) instill 1 drop in both eyes two times [NAME] for dry eyes;* an order dated 03/31/26 for calcium 500+D3 500 mg-5 mcg (to treat malnutrition) give 1 tablet two times [NAME] for supplement related to calorie-protein malnutrition;* an order dated 06/11/26 for Milk of Magnesia (laxative)suspension 2400 mg/30 ml give 30 ml two times a day for constipation;* an order dated 07/01/26 for alprazolam (to treat anxiety) 0.5 mg give 1 tablet three times a day for anxiety disorder; and* an order dated 06/18/26 for gabapentin (to treat pain) 400 mg give 1 capsule three times [NAME] for neuropathy. Record review of a MedPass Schedule received via email from the Administrator on 08/17/26 at 10:36 a.m. indicated:* QD/one time a day medication was administered from 06:00 a.m. to 10:00 a.m.;* BID/two times a day medication was administered from 06:00 a.m. to 10:00 a.m. and from 06:00 p.m. to 10:00 p.m.; * TID medication was administered at 08:00 a.m., 02:00 p.m., and 08:00 p.m.; and* QID medication was administered at 09:00 a.m., 12:00 p.m., 05:00 p.m., and 09:00 p.m. Record review of the July 2026 MAR for Resident #1 indicated:* on 07/02/26 the 01:00 p.m. dose of alprazolam 0.5 mg was not administered;* on 0712/26 the daily doses of amlodipine besylate 5 mg, aspirin chewable tablet 81 mg, docusate sodium 100 mg, glycolax powder give 17 gram mix with4-8oz water, levofloxacin 750 mg, Metoprolol Succinate Extended Release 50 mg, and Lexapro 10 mg were not administered;*on 07/12/26 the morning dose of artificial tears, calcium 500+D3 500 mg-5 mcg, Milk of Magnesia suspension 2400 mg/30 ml, alprazolam 0.5 mg, and gabapentin 400 mg were not administered;* on 07/12/26 the 01:00 p.m. dose of alprazolam 0.5 mg was not administered; * on 07/19/26 the 01:00 p.m. dose of alprazolam 0.5 mg was not administered; and * on 07/22/26 the 01:00 p.m. dose of alprazolam 0.5 mg was not administered. Record review of the Progress Notes for Resident #1 had no nurse notes dated 07/02/26, 07/12/26, 07/19/26, or 07/22/26 of the missed doses of medications, Record review of the August 2026 MAR for Resident #1 indicated on 08/12/26 the resident had a pulse rate of 51 (<60) and the Metoprolol Succinate Extended Release 50 mg was administered. Record review of the Progress Notes for Resident #1 had no nurse note dated 08/12/26 indicating the physician was notified of the low pulse rate and whether to administer the medication or to hold per orders. During an observation and interview on 08/17/26 at 12:35 p.m. Resident #1 said she did not always get her medications. During the interview MA B entered the room to give Resident #1 the 01:00 p.m. dose of alprazolam 0.5 mg. After Resident #1 took the pill and drank some water, she stuck her tongue out to show MA B she had swallowed the pill. However, after MA B left the resident room, Resident #1 proceeded to spit out the pill in front of the surveyor. She said she did not want to take it because it was the pain pill she did not like to take. Surveyor told Resident #1 the medication MA B gave her was for her anxiety and not a pain pill. Resident #1 then put the pill back in her mouth and swallowed it with water. During an interview on 08/17/26 at 01:04 p.m. LVN A and MA B were told by surveyor about Resident #1 spitting the pill out because she thought it was a pain pill. LVN A and MA B said Resident #1 was known for refusing medications but she was not known to spit them out after staff left the room. Resident #2Record review of a face sheet dated 08/17/26 indicated Resident #2 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included hypertension (a condition in which the force of the blood against the artery walls is too high), and chronic embolism and thrombosis of the arteries of the lower extremities (formation of blood clots). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #2's BIMS was 07 out of 15 indicating she had severely impaired cognition. Record review of the care plan dated 07/29/26 indicated Resident #2's diagnoses were addressed and appropriate goals and interventions were in place including an intervention to administer medications as ordered. Record review of August 2026 physician orders for Resident #2 indicated:* an order dated 04/12/23 for a Lisinopril (to treat high blood pressure) Tablet 5 mg give 1 tablet one time a day for hold SBD< 100 or DBP < 60 for hypertension;* an order dated 10/27/23 for aspirin chewable tablet 81 mg give 1 tablet one time a day related to chronic embolism and thrombosis of the arteries of the lower extremities; and* an order dated 04/01/26 for Metoprolol Tartrate (to treat high blood pressure) 25 mg give 1 tablet one time a day hold SBP< 100 or DBP< 60, or heart rate < 60 for hypertension. Record review of the July 2026 MAR for Resident #2 indicated:* on 07/02/26 the daily doses of Lisinopril 5mg and Metoprolol Tartrate 25 mg were administered with SBP of 76 and DBP of 47;* on 07/11/26 the daily dose of Metoprolol Tartrate 25 mg was not administered with SBP of 120 and DBP of 67; there was no documentation of the heart rate; *on 07/12/26 the daily doses of aspirin chewable tablet 81 mg, Lisinopril 5mg, and Metoprolol Tartrate 25 mg were not administered;* on 07/14/26 the daily doses of Lisinopril 5mg and Metoprolol Tartrate 25 mg were held with SBP of 104, DBP of 63, and heart rate of 68; * on 07/24/26 the daily doses of Lisinopril 5mg and Metoprolol Tartrate 25 mg were administered with SBP of 90 and DBP of 51; * on 07/27/26 the daily doses of Lisinopril 5mg and Metoprolol Tartrate 25 mg were administered with SBP of 98 and heart rate of 58;* on 07/30/26 the daily dose of Metoprolol Tartrate 25 mg was not administered with SBP of 94 and DBP of 49; and * on 07/31/26 the daily doses of Lisinopril 5mg and Metoprolol Tartrate 25 mg were administered with DBP of 56. Record review of the Progress Notes for Resident #2 had no nurse notes dated 07/02/26, 07/11/16, 07/12/26, 07/14/26, 07/24/26, 07/27/26, 07/30/26, or 07/31/26 of the irregularities with the doses of medications. Record review of the August 2026 MAR for Resident #2 indicated on 08/06/26 the daily doses of Lisinopril 5mg and Metoprolol Tartrate 25 mg were administered with DBP of 50. Record review of the Progress Notes for Resident #2 had no nurse note dated 08/06/26 indicating the physician was notified of the low DBP and whether to administer the medication or to hold per orders. During an interview on 08/17/26 at 12:45 p.m. Resident #2 said she received medications from the staff and as far as she knew she received them all. Resident #3Record review of a face sheet dated 08/17/26 indicated Resident #3 was a [AGE] year-old male admitted on [DATE]. His diagnoses included hypertension (a condition in which the force of the blood against the artery walls is too high), depression (mental illness that negatively affects how you feel, the way you think and how you act), cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), overactive bladder (a common condition where there is a frequent feeling of needing to urinate to a degree that negatively affects a person's life), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and pain. Record review of the significant change MDS assessment dated [DATE] indicated Resident #3's BIMS was 07 out of 15 indicating he had severely impaired cognition. Record review of the care plan dated 05/27/26 indicated Resident #3's diagnoses were addressed and appropriate goals and interventions were in place including an intervention to administer medications as ordered. Record review of August 2026 physician orders for Resident #3 indicated:* an order dated 06/02/26 for a Lisinopril Tablet 20 mg give 1 tablet one time a day for hold SBD <110 and DBP <60, Pulse <60 for hypertension;* an order dated 07/17/26 for Mirtazapine (to treat depression) 7.5 mg give at bedtime for depression;* an order dated 05/29/26 Nifedipine (to treat high blood pressure) Extended Release 60 mg give 1 tablet one time [NAME] for hypertension for 60 Days hold if DBP <120 and SBP <60, heart rate <60;* an order dated 05/23/26 for aspirin chewable tablet 81 mg give 1 tablet one time a day for cerebral infarction;* an order dated 05/23/26 for oxybutynin (to treat overactive bladder) chloride Extended Release 10 mg give 1 tablet one time a day for overactive bladder;* an order dated 05/23/26 for metformin (to treat elevated blood sugar) 1000 mg give 1 tablet two times a day for blood glucose;* an order dated 05/23/26 for Gabapentin 100 mg give 1 capsule three times a day for pain; Record review of the July 2026 MAR for Resident #3 indicated:* on 07/11/26 the daily doses of aspirin chewable tablet 81 mg, Lisinopril Tablet 20 mg, Nifedipine Extended Release 60 mg, and oxybutynin chloride Extended Release 10 mg were not administered with a number 9 noted; * on 07/11/26 the morning doses of metformin 1000 mg and Gabapentin 100 mg were not administered with a number 9 noted; * on 07/11/26 the 01:00 p.m. dose of Gabapentin 100 mg was not administered with a number 9 noted;* on 07/15/26 the daily dose of Nifedipine Extended Release 60 mg was not administered with a number 9 noted; * on 07/19/26 the 01:00 p.m. dose of Gabapentin 100 mg was not administered with no documentation on the MAR; * on 07/22/26 the bedtime dose of Mirtazapine 7.5 mg was not administered with no documentation on the MAR; and* the Chart Codes on the MAR indicated number 9 was for Other/See Progress Notes Record review of the Progress Notes for Resident #3 had no nurse notes dated 07/11/16, 07/15/26, 07/19/26, or 07/22/26 of the irregularities with the doses of medications. Record review of the August 2026 MAR for Resident #3 indicated on 08/01/26 the bedtime dose of Mirtazapine 7.5 mg was not administered with no documentation on the MAR. Record review of the Progress Notes for Resident #3 had no nurse note dated 08/01/26 indicating the physician was notified of the missed dose of Mirtazapine 7.5 mg. During an interview on 08/17/26 at 12:48 p.m. Resident #3 said he did not think he had any issues with his medications. Resident #4Record review of a face sheet dated 08/17/26 indicated Resident #4 was a [AGE] year-old male admitted on [DATE]. His diagnoses included seizures (surge of excessive electrical activity may cause involuntary movements, sensations, emotions, and/or behaviors), Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #4's BIMS was 07 out of 15 indicating he had severely impaired cognition. Record review of the care plan dated 07/29/26 indicated Resident #4's diagnoses were addressed and appropriate goals and interventions were in place including an intervention to administer medications as ordered. Record review of August 2026 physician orders for Resident #4 indicated the following:* an order dated 04/26/25 for Levetiracetam (to treat seizures) 500 mg give 1 tablet every 12 hours for seizures; * an order dated 07/18/24 for Metoprolol Tartrate 50 mg give 1 tablet two times a day hold SBP< 100, DBP< 60, and/or HR <65 for hypertension; and * an order dated 06/22/24 for Carbidopa-Levodopa (to treat Parkinson's) 25 mg-100 mg give 1 tablet four times a day for Parkinson's.* an order dated 12/04/19 for Enalapril Maleate (to treat high blood pressure) 20 mg give 1 tablet one time a day hold if SBP<100 or DBP<60 or HR<60 for hypertension. Record review of the July 2026 MAR for Resident #4 indicated:* on 07/01/26 the evening dose of Metoprolol Tartrate 50 mg was administered with a heart rate of 62;* on 07/02/26 the 12:00 p.m. dose of Carbidopa-Levodopa 25 mg-100 mg was not administered with no documentation on the MAR;* on 07/02/26 the evening dose of Metoprolol Tartrate 50 mg was administered with a heart rate of 62;* on 07/02/26 the 09:00 p.m. dose of Carbidopa-Levodopa 25 mg-100 mg was not administered with no documentation on the MAR;* on 07/07/26 the morning dose of Metoprolol Tartrate 50 mg was administered with a heart rate of 64;* on 07/14/26 the evening dose of Metoprolol Tartrate 50 mg was administered with a heart rate of 60;* on 07/15/26 the daily dose of Enalapril Maleate 20 mg was not administered with a number 9 noted;* on 07/15/26 the evening dose of Metoprolol Tartrate 50 mg was administered with a heart rate of 63;* on 07/22/26 the evening dose of Levetiracetam 500 mg was not administered with no documentation on the MAR;* on 07/22/26 the 09:00 p.m. dose of Carbidopa-Levodopa 25 mg-100 mg was not administered with no documentation on the MAR; and * on 07/30/26 the 09:00 p.m. dose of Carbidopa-Levodopa 25 mg-100 mg was not administered with no documentation on the MAR. Record review of the Progress Notes for Resident #4 had no nurse's notes dated 07/01/26, 07/02/26, 07/07/26, 07/14/16, 07/22/26, or 07/30/26 addressing the irregularities with the doses of medications. A nurse's note dated 07/15/26 indicated they were waiting for the pharmacy delivery but no other documentation of if the medication was given or the physician being notified of the missed dose. Record review of the August 2026 MAR for Resident #4 indicated: * on 08/01/26 the 09:00 p.m. dose of Carbidopa-Levodopa 25 mg-100 mg was not administered with no documentation on the MAR;* on 08/01/26 the evening dose of Levetiracetam 500 mg was not administered with no documentation on the MAR;* on 08/13/26 the evening dose of Metoprolol Tartrate 50 mg was administered with a heart rate of 63;* on 08/14/26 the morning dose of Metoprolol Tartrate 50 mg was administered with a heart rate of 64; Record review of the Progress Notes for Resident #4 had no nurse's note entry dated 08/01/26 indicating the physician was notified of the missed dose of Carbidopa-Levodopa 25 mg-100 mg and Levetiracetam 500 mg. There was also no nurse's note entry dated 08/13/26 or 08/14/26 of the physician being notified of the low HR and whether to hold the Metoprolol Tartrate 50 mg or administer it. During an interview on 08/17/26 at 12:55 p.m. Resident #4 said the staff gave him his medications. During an interview on 08/17/26 at 01:05 p.m. LVN A and MA B acknowledged the irregularities with the medication administration for Residents #1, #2, #3, and #4. They said if the residents did not receive their medications as ordered they would not be at the therapeutic level needed. During an interview on 08/17/26 at 03:45 p.m. the DON and the Administrator acknowledged the irregularities with the medication administration for Residents #1, #2, #3, and #4. The DON said she expected staff to administer medications according to the orders given by the physician. The DON said if a medication was not documented as being administered on the MAR then it was not administered. The DON said medications should have the appropriate parameters and the parameters should be followed as to give the medication or hold it. The DON said the ADONs were to check the MARs at least monthly. The DON said an adverse outcome would be residents not receiving the therapeutic dose of the medication. The Administrator said she also expected the medications to be given according to the physician orders otherwise residents could not benefit from the medications they receive. Record review of the General Guidelines for Medication Administration revised 08/2020 indicated: Policy Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions_ Nursing policies developed by the facility may supersede the procedures outlined in this policy. Procedures. II. Administration1. Medications are administered only by licensed nursing. medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications.2. Medications are administered in accordance with written orders of the prescriber. IV. Documentation (including electronic)1. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure that necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications.4. The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR are cross--referenced to a full signature in the space provided.6. If a dose of regularly scheduled medication is withheld, refused, not available. or given at a time other than the scheduled time {e.g., the resident is not in the facility at a scheduled time or a starter dose of an antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. If 3 consecutive doses, or in accordance with facility policy, or a vital medication are withheld, refused, or not available, the physician is notified. Nursing documents the notification and physician response.7. If an electronic MAR system is used, specific procedures required for resident identification, identification of medications due at specific times, and documentation of administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's user manual. These procedures should be followed, and may differ slightly from the procedures for using paper MARs. Electronic systems also describe procedures for secure access, maintaining privacy of resident information, and for electronic signatures. Maintenance and support procedures for these systems are described in the system user manuals. Procedures will vary between the various electronic systems available.

Based on observations, interviews, and record review, the facility failed to store and prepare food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food items in the refrigerator were dated and labeled appropriately. 2. The facility failed to discard food stored in the refrigerator that should no longer be consumed. These failures could place residents at risk for food-borne illness and food contamination. The findings included: An observation of the facility's refrigerator on 04/14/26 beginning at 10:05 a.m. revealed the following: - A cylinder food container labeled salad with a use by 4/11/26. No other information was provided.- A cylinder food container labeled pasta with a use by 4/12/26. No other information was provided.- A cylinder food container labeled corn with item 4/2/26. No other information was provided.- A transparent, resealable plastic storage bag of food without any label or dates. During an interview and observation with [NAME] A on 04/14/26 at 10:07 a.m., [NAME] A began to remove the transparent, resealable bag of food. She stated the food in the bag was potato salad from last night. She stated it should have been labeled and dated before it was placed in the refrigerator and included a date that it should be removed. She stated the cooks were responsible for labeling and discarding food. She stated the failure could cause the residents to receive spoiled food.During an interview with the Administrator on 04/14/26 at 01:15 p.m., she stated she fired the DM on April 7th, 2026. She currently has a PRN DM. She stated all food should be labeled with what it was, the date it expired, and the date it was originally placed in the refrigerator. She stated this would let dietary staff know when it could no longer be used and needed to be discarded. She said the cook was responsible for these expectations, and the DM should be checking daily to make sure it was done correctly. She stated recently she had done in-services of these expectations. She stated the failure could cause contamination, infection, and/or food poisoning of the residents. During an interview with the DM on 04/15/26 at 08:40 a.m., she stated she was PRN and normally visited the facility in the morning and evenings. The DM stated her expectations included that all food should be labeled and dated. Food should be removed based on the dates provided. She stated they were responsible to label what the food was, the date it was opened, and the facility included a discard date. She stated the discard date could be determined by looking at the date opened and it should be discarded or used within 7 days later. She stated any staff with a food handlers' certificate were responsible for these expectations. She stated everyone in the kitchen needed to follow these expectations, and she ensured they followed them. She stated the failures could cause food borne illness and cause the residents to get sick. Review of the facility's policy, Left-over Foods dated 02/26, reflected, .Left-over food should be handled in a manner to prevent the spread of food borne illness.2. Left-over foods should be dated, labeled, and covered after meal services.4. Left-over foods should be refrigerated and used within 3 days or frozen for later use. 6. Any foods that have a manufacturer's expiration or use-by date should be left in the original container and should be discarded according to this date . Record review of the 2022 Food Code dated 01/18/23 indicated 3-305.11 Food shall be protected from contamination by storing the food: . (2) Where it is not exposed to splash, dust, or other contamination.3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date . Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. Date marking requirements apply to containers of processed food that have been opened and to food prepared by a food establishment, in both cases if held for more than 24 hours, and while the food is under the control of the food establishment. This provision applies to both bulk and display containers. It is not the intent of the Food Code to require date marking on the labels of consumer size packages. A date marking system may be used which places information on the food, such as on an overwrap or on the food container, which identifies the first day of preparation, or alternatively, may identify the last day that the food may be sold or consumed on the premises. A date marking system may use calendar dates, days of the week, color-coded marks, or other effective means, provided the system is disclosed to the Regulatory Authority upon request, during inspections.

Based on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of eleven residents reviewed for quality of care. The facility failed to thoroughly document measurements of two skin openings on Resident #1's bilateral (both sides) buttocks and notify the MD or NP regarding two skin openings that were present on admission. This failure could place residents at risk of not receiving necessary medical care and deterioration of the skin.Findings included: Review of Resident #1's face sheet revealed a [AGE] year-old man admitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus (where your body does not make enough insulin or cannot use insulin properly leading to high blood sugar), Chronic Obstructive Pulmonary Disease (COPD - a progressive lung disease that blocks airflow, making breathing difficult), and Acute and Chronic Respiratory Failure (when lungs cannot get enough oxygen or remove enough carbon dioxide). Review of Resident #1's MDS Resident Assessment and Care Screening dated 11/15/2025 revealed the following:*a BIMS score of 10 which indicated moderate cognitive impairment. *Under the skin condition section; Is the resident at risk of pressure ulcers/injuries; A 1 was entered which indicated Yes. *Under other ulcers, wounds, and skin problems section; under other problems listed as open lesions, surgical wounds, burns, skin tears, moisture associated skin damage; the box next to none of the above were present was checked. Review of Resident #1's care plan dated 11/14/2025 revealed I am at risk for frequent infections, pressure/venous/statis ulcers (types of wounds), hyper/hypoglycemia (high and low blood sugar), renal (kidney) failure, cognitive/physical impairment, skin desensitized to pain or pressure related to diabetes mellitus.monitor/document/report PRN s/sx of hyperglycemia.poor wound healing. Review of Resident #1's weekly skin assessments from 11/13/2025 to 11/30/2025 revealed all five documented the exact same information. They stated there was moisture associated skin damage; redness, excoriation (scratching, scraping, or wearing off the skin), and small open area on sacrum; Does the resident have a pressure, venous, arterial, diabetic, or surgical wound? (types of wounds); No. Review of Resident #1's nursing progress notes from 11/13/2025 to 12/03/2025 revealed no notes regarding skin integrity or notification of skin integrity to MD, NP, or family. During an observation on 12/03/2025 at 09:31 a.m., revealed Resident #1 in his room on his bed. He stated he did not really have any concerns. He stated he had some pain (generalized pain due to cancer) and therefore he completed physical therapy in bed. He stated his bottom was sore and they put cream on his bottom. He stated, I wish they would do more (for his bottom). He stated they were good at taking care of stuff. At this point, an observation was made of Resident #1's bottom. There was a small circular skin opening on one side of his buttocks and what appeared to be another opening, a small slit on the other buttock. Review of Resident #1's weekly skin assessment, dated 12/03/2025, after surveyor intervention was documented by the ADON and revealed Bilateral Buttocks -Left buttock mostly red blanchable chaffed and right buttocks mostly red blanchable and chaffed.left buttock has an area that is that is opened 1 x 1 right buttock area that is opened 0.5 x 0.1 areas looks more like excoriation. Review of Resident #'1s nursing progress notes, dated 12/03/2025 at 2:09 p.m., after surveyor intervention revealed This nurse notified np of opened area to bital (bilateral) buttocks received a order to clean with wound cleanser apply collagen cover with hydrocolloid change every three days resident is his own rp and was notified site was cleaned and treat (treatment) applied.Review of Resident #1's physician orders, dated 12/04/2025 revealed no orders for impaired skin integrity up to 12/03/2025, after surveyor intervention revealed excoriation to the left buttocks - cleanse with wound cleanser, pat dry, apply collage to opened area, cover with hydrocolloid dressing one time a day with a start date of 12/03/2025 and excoriation to the right buttocks - cleanse with wound cleanser, pat dry, apply collage to opened area, cover with hydrocolloid dressing one time a day with a start date of 12/03/2025. During an interview on 12/03/2024 at 09:59 a.m., the ADON stated she was the ADON and treatment nurse. She handled all major wounds. She stated the floor nurses care for excoriation, skin tears, and moisture associated skin damage. She stated if there was any opening to the skin, she would put her eyes on the skin issues to determine what we got and what we are dealing with. She said I normally would refer them to the wound care NP.to have another set of eyes. Unless they are hospice, I ask hospice for their eyes. The ADON stated the floor nurses completed weekly skin assessments. She stated the assessments should include measurements, how it looks, if it is getting worse or better. The ADON stated she was not aware of Resident #1 having a skin opening. During an interview on 12/03/2025 at 10:43 a.m., LVN B stated on admission a full assessment was to be completed. If there was an issue found, call the MD and document the MD was notified in the nursing progress notes. A skin assessment note was to be completed as well. LVN B stated if there was an opening in the skin, measure it, note if there was drainage, and provide dimensions. LVN B stated if there were any skin openings, always measure it to determine if it was getting better. She stated if there were no measurements, it could get worse. She stated nurses should tell the treatment nurse about any skin issues that were found. LVN B stated she has been trained by specialists as well as the treatment nurse on the expectations regarding skin integrity assessments and care. During an interview on 12/04/2025 at 7:58 a.m., the ADON stated she notified the MD and NP yesterday regarding Resident #1's skin concern. She stated new orders were entered, a dressing was initiated on the MAR, completed a new nursing note, and a new skin assessment was completed. She stated a small spot could get worse within 24 hours. During a telephone interview on 12/04/2025 at 10:25 a.m., the NP stated the facility normally let her know of any skin issues found and if they needed wound care. She stated she was normally informed of all skin issues, at a minimum by text. She stated she was contacted regarding Resident #1's skin yesterday (12/03/25). The NP stated what could happen depended how bad the skin was. Some residents have become septic (infection of the blood) and were sent out to the hospital. Normally staff provide measurements, describe the skin issue, and sometimes I receive pictures. The NP stated she was not previously notified of that specific skin issue before 12/03/2025. Review of in-service titled Admit/Readmit Skin Assessments, no date, revealed the charge nurse must complete a head to toe skin assessment upon admit/re-admit and note all skin issues on admission assessment and skin assessment as scheduled on admit packet.Charge nurse must put a treatment order for all skin issues upon admit/re-admit.MD and RP must be notified of all skin issues upon admission. Review of facility policy titled Skin Management: Prevention and Treatment of Wounds revised 10/06/2022 revealed The purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds.licensed nurse will perform head to toe assessment on all new admissions/readmissions.monthly pressure and non-pressure log will be updated weekly and sent to the Regional Director of Clinical Operations on Friday.Residents with skin wounds will have corresponding diagnosis documented in the chart.

Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 3 of 24 residents (Residents #27, #8 and #23) reviewed for nutrition. 1.The facility did not ensure dietary recommendations was implemented for Resident #27. 2.The facility failed to ensure orders for fortified oatmeal was implemented for Resident #8. 3.The facility failed to ensure Resident #23 had water in his cup to drink on 08/25/25. These failures could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization.Findings included: 1. Record review of Resident #27's face sheet, dated 08/28/25, reflected Resident #27 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included partial intestinal obstruction (partial blockage in the intestines that prevent food, stool, and gas from passing through normally). Record review of the order summary report dated 08/28/25 reflected Resident #27 had an order for fortified cereal with breakfast and 4 oz fortified oatmeal with lunch with a start date 07/23/24. Record review of Resident #27's quarterly MDS assessment, dated 08/22/25, reflected Resident #27 usually made herself understood and usually understood others. Resident #27's BIMS score was 10, which reflected her cognition was moderately impaired. The assessment reflected Resident #27 had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Resident #27 was not a physician-prescribed weight loss regimen. Record review of Resident #27's undated comprehensive care plan reflected Resident #27 had an alteration in gastro-intestinal related to disease process. The care plan interventions included avoid lying down for at least 1 hours after eating and avoid food or beverages that tend to irritate esophageal (muscular tube that connects the throat to the stomach) lining. Record review of Resident #27's nutrition note completed by the dietitian dated 08/18/25 reflected Recommend to add fortified oatmeal to breakfast for additional calories and protein daily. Record review of Resident #27's meal ticket dated 08/27/25 reflected resident request cereal only for breakfast/fortified cereal. During an observation on 08/27/25 at 9:00 a.m., Resident #27 received a bowl of dry cereal and a glass of milk instead of fortified cereal. During an interview on 08/27/25 at 9:07 a.m., the Dietary Manager stated Resident #27 requested dry cereal for breakfast. The Dietary Manager stated the fortified cereal was oatmeal which included evaporated milk and brown sugar for additional calories and protein. The Dietary Manager stated her assumption was if Resident #27 not eating the fortified oatmeal she should be ordered med pass 2.0 (provide supplement calories and protein) but she assumed the nursing department would know to offer it. The Dietary Manager stated the Dietician has never told her to offer med pass 2.0 but she assumed the nursing department would know to offer it based off assumption. The Dietary Manager stated she did not know anything about her receiving fortified with oatmeal with lunch. The Dietary Manager stated that was an error that need to be corrected. The Dietary Manager stated she had not contacted the Dietitian to inform her Resident #27 preferred dry cereal over the fortified cereal. The Dietary Manager stated not following the dietary recommendation could possibly prevent weight loss. During an interview on 08/27/25 at 9:07 a.m., LVN A stated she had no clue why Resident #27 should receive fortified cereal. LVN A stated she was unaware that med pass 2.0 should be offered with dry cereal to replace the fortified cereal. LVN A stated usually if med pass 2.0 need to be offered it would be on their meal ticket. LVN A stated it was important for her to receive her fortified cereal to prevent weight loss. During an interview on 08/27/25 at 9:11 a.m., Resident #27 stated she did prefer dry cereal for breakfast over oatmeal. Resident #27 stated if the facility would have offered the med pass 2.0, she would try it, but she had never been offered it. During a telephone interview on 08/27/25 at 9:38 a.m., the Dietitian stated she added the fortified meal to her breakfast on last week because Resident #27 triggered for weight loss, and the Dietitian would like her for to receive additional calories and protein. The Dietician stated the first line of treatment would be to add fortified cereal in addition to her breakfast. The Dietician stated if the resident did not like the fortified cereal, she would put in a note to have the cereal change to med pass 2.0. The Dietitian stated she should have been notified that Resident #27 requested dry cereal for breakfast, and she would have documented and changed for her to receive med pass 2.0. The Dietician stated med pass 2.0 was given with medication administration. The Dietitian stated it was important to follow the recommendation to prevent further weight loss. During an interview on 08/28/25 at 1:50 p.m., the DON stated she became aware this week that Resident #27 did not like the fortified cereal. The DON was unable to give the exact date. The DON stated staff should have notified her if she did not prefer the fortified oatmeal to discuss with the dietitian and offer the resident a different option. The DON stated she monitored dietary recommendations during the SOC meetings on Wednesday evenings to discuss any issues with the care of the resident. The DON stated it was important for recommendations to be followed so the resident can receive nutrients and to maintain her weight. During an interview on 08/28/25 at 3:39 p.m., the Administrator stated her expectation was Resident #27 received the fortified cereal with the dry cereal. The Administrator stated if Resident #27 did not like the fortified cereal the CNA should report it to the charge nurse, and the charge nurse should report it to the DON. The Administrator stated the DON was responsible for monitoring dietary recommendation. The Administrator stated it was important for the dietary recommendation to be followed to prevent weight loss and to see what a substitute for her preference would be to maintain the calorie intake. 2. Record review of Resident #8's face sheet dated 09/03/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses of history of falls, dementia (group of conditions that cause a decline in cognitive abilities), anxiety, and high blood pressure. Record review of Resident #8's annual MDS dated [DATE] indicated she usually understood others and was usually understood by others. The MDS also indicated she had a BIMS score of 6 which meant she had severe cognitive impairment. The MDS also indicated she required moderate assistance from staff for bed mobility, transfers, bathing, and she required setup for eating. Record review of Resident #8's care plan revised 08/25/25 indicated she required a mechanical soft carb-controlled diet with fortified oatmeal at lunch and supper with interventions to serve diet as ordered and offer substitute if less than 50% is eaten. Record review of Resident #8's order summary report dated as of 08/28/25 indicated she had an order for: Carb controlled diet mechanical soft texture, regular consistency, (no added salt) and 4 ounces fortified oatmeal with lunch and supper with a start date of 06/20/24 and no end date. Record review of Resident #8's order audit report dated 08/26/25 indicated her dietary order was updated on 08/25/25 after surveyor intervention from resident receiving 4 ounces of pudding with lunch and dinner to 4 ounces of fortified oatmeal at lunch and dinner completed by the DON. Record review of Resident #8's meal tray card dated 08/26/25 indicated her tray was supposed to include 4-ounce fortified pudding. During an observation on 08/25/25 at 12:34 PM during the lunch meal Resident #8 was sitting in the dining room with her tray. The meal tray card indicated fortified pudding and a health shake and the tray did not have a shake nor fortified pudding on it. During an observation on 08/26/25 at 12:20 PM during the lunch meal Resident #8 was sitting in the dining room with her tray. The tray did not have fortified oatmeal nor fortified pudding on it. During an interview on 08/27/2025 at 2:20 PM the Dietary Manager said the cook on duty was responsible for ensuring the residents had the proper supplements on the trays matching their meal tray cards and the nurse was to ensure the card matched what was on the tray. She said she expected the cook to make fortified potatoes on 08/25/25 and Resident #8 should have gotten med pass 2.0 as a substitute for a shake because the facility no longer gets shakes due to a nationwide outage. The Dietary Manager said Resident #8 should have had potatoes on 08/26/25 as well and the cards just needed updated. She said the failure placed Resident #8 at risk of weight loss and not getting the proper nutrition. During an interview on 08/28/2025 at 4:05 PM the DON said she expected all residents to be served supplements as ordered. She said she discussed diets and supplements with the Dietary Manager weekly at the standards of care meeting and the DON told her what to input on the meal tray cards. The DON said the failure placed a risk for Resident #8 having weight loss or prevent resident from receiving the proper nutrition. During an interview on 08/28/2025 at 4:35 PM the Administrator said she expected Resident #8 to receive her meal with the proper supplements ordered. The Administrator stated it was important for the diet orders to be followed to prevent weight loss. 3.Record review of Resident #23's face sheet dated 08/28/25 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the diagnoses of Guillain-Barre syndrome (a condition in which the autoimmune system attacks the nerves), acute kidney failure, systemic sclerosis (a rare disease that causes the body to produce too much collagen causing contractures ad skin thickening), benign prostatic hypertrophy (enlarged prostate gland causing difficult urination), and need for assistance with personal care. Record review of Resident #23's quarterly MDS dated [DATE] indicated he was usually able to make himself understood and usually understood others. The MDS also indicate he had a BIMS score of 13 which meant he was cognitively intact. The MDS also indicated he required moderate assistance from staff for toileting, bed mobility and bathing and required setup for eating. The MDS also indicated he was incontinent of bowel and bladder. Record review of Resident #23's care plan revised on 07/28/25 indicated he had a potential discomfort, and complications related to a diagnosis benign prostatic hypertrophy with interventions to encourage adequate fluid intake to reduce the risk of UTI. During an observation and interview on 08/25/2025 at 11:08 AM Resident #23 had no water in his water cup and he said he had not had any all day. During an interview on 08/28/2025 at 4:01 PM the DON said she said she expected the water was being passed by the CNAs. The DON said she did spot check at times to ensure it was being completed. She said the failure placed a risk for Resident #23 to have dehydration. During an interview on 08/28/2025 at 4:37 PM the Administrator said her expectation was for the CNAs to pass water to the residents every shift. The administrator said Resident #23 would usually voices his concerns with her, but he should have water. She said the failure placed Resident #23 at risk for dehydration. Record review of the facility policy Supplements revised 6/2025 indicated: Policy The community may provide additional nutrients to the residents through the use of physician ordered supplements. Procedure 1. Recommendations for house supplements may be initiated by the interdisciplinary care team. 2. All supplements must be ordered by a physician.3. Fortified items must be implemented as recommended.5. Supplements ordered from the kitchen are noted on the tray card.

Based on observation, interview, and record review, the facility failed to follow the menu according to 2 of 3 resident councils and 1 of 1 meal (the lunch meal) reviewed. 1. The facility failed to follow the menu for the lunch meal served on 08/25/25. 2. The facility failed to serve what was printed on the residents' tray cards or posted in the kitchen as mentioned in resident council meetings held on 06/03/25 and 08/26/25. These failures could place residents who consume food prepared by the facility's kitchen at risk of not having their nutritional needs met and/or experiencing weight loss.Findings included: During an interview on 08/25/25 at 11:57 a.m., Resident #65 said she was tired of not getting what was printed on the menu. She said they hardly ever had what was printed on her tray card. During an interview on 08/25/25 at 12:10 p.m., CNA C said Resident #65 was correct. She said often what was written on their tray cards was not what was being served. CNA C said residents often got upset because of what was served versus what was supposed to have been served. She said she would often have to go to the kitchen and get the residents a substitute. Record review of the weekly menu provided by the facility revealed the lunch meal scheduled for Monday, 08/25/25, Day #25 of the third week: chicken fried steak, green beans, mashed potatoes, strawberry cake, and roll. There was no sign posted indicating any deviations from the menu. During an observation on 08/25/25 at 12:30 p.m., the lunch meal served to residents in the dining room revealed they were served chicken-fried steak, mixed vegetables, au gratin potatoes, bread, and Jello. Record review of the facility's resident council minutes dated 06/03/25 indicated, menus not followed. During the resident council meeting held by the state surveyor on 08/26/25, starting at 10:00 am, revealed that 10 of 10 residents agreed that meals were not served as posted on the menu. During an interview on 08/27/25 at 9:45 a.m., the Registered Dietitian consultant said she expected staff to follow the menu. She said the facility was supposed to notify her of any substitutes, and she would let the facility know what to serve. She said she visited the facility weekly and was not aware of any substitutes lately . She said any changes should have been posted properly in the dining room so residents would know what they would be served. During an interview on 08/27/2025 at 11:28 a.m., [NAME] G said she had not had to alter the menu, but maybe on Mondays when they were waiting on the food delivery truck to arrive. She said if she had to deviate from the menu, she would call the Dietary Manager and she would tell her what to use, or if possible, the Dietary Manager would go pick it up from the local store. She said that when she did deviate from the menu, she only wrote it on the kitchen menu. She said she did not write it on the residents' board posted in the dining room. During an interview on 08/27/25 at 2:17 p.m., the Dietary manager said she did not know why the menus had been changed on Monday (08/25/25) because she was not at the facility. She said she knew the menu had been changed (unknown dates), mostly over the weekend, because the staff had let her know after the fact. She said she had done in-services and write-ups with staff in the past, but none lately on following the menu. She said they could not locate the substitution approval form log for August 2025. She said it was her responsibility to ensure meals were served according to the menu posted and signed by the consultant Regional Dietitian for any changes. She said it was important to follow the menu for her budget and the right nutrition. She said if the residents were not getting the right nutrition, it could lead to weight loss. During an interview on 08/28/25 at 2:34 p.m., the DON said she expected the dietary staff to serve and follow the scheduled menu. She said it was the Dietary Manager's responsibility to ensure the dietary staff was serving the correct menu. She said she knew the residents had expressed to the Administrator that the dietary staff was not following the menus. She said the kitchen should communicate any changes because it causes the residents to be upset and could potentially result in residents not eating or losing weight. During an interview on 08/28/25 at 3:13 p.m., the Administrator said she was aware that the facility was not serving meals as posted on the weekly menu in the past, as noted in the resident council minutes. She said she had placed the Dietary Manager on a performance improvement plan some months past, but thought the dietary department was doing better by following the menus. She said the Dietary Manager was aware that if any substitutions were done, they needed to be logged on a menu substitution approval form and approved by the Regional Dietitian . She said any changes should also be posted on the menu in the dining room for effective communication with the staff and residents. She said food was important for the residents, and failure to follow the menu could lead to residents not eating. Record review of the Menu Substitution Approval Form was not produced by the facility . This form must contain the following: Menu date and service date (the date the substitution was being served), Original Menu Item: (The meal item that was being replaced), the reason for the Substitution, and the full name of the qualified dietitian approving the change. Nutritional Equivalency: A statement confirming that the substitute was comparable in nutrient content to the original item. The signature of the dietitian, the date the substitution was approved, which must be before the meal was served. Facility documentation: The facility must record and retain all substitution forms with the menu as served. Menus, including any substitutions, must be kept on file for at least 30 days. During an interview on 08/28/25 at 3:30 p.m., the Regional Nurse Consultant said they did not have a policy on menus or substitutions but provided a policy on meal service. Record review of the facility's policy titled, Meal Service, reviewed 04/2022, indicated, Policy: The dining experience will enhance the resident's quality of life and recognize the resident's needs during dining to achieve a nutritional meal. Resident meals will be posted and served at regular times not to exceed 14 hours. Procedure: .#19. Alternatives are offered to residents who express a dislike for any of the food items. The alternative is from the same group as the food/foods refused. Food and Nutrition Services posts the alternates available prior to the meal.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 2 of 23 residents (Resident #67 and Resident #87) and 1 of 1 lunch meals reviewed for palatability. The facility failed to provide food that was palatable and attractive to Resident #67 and Resident # 87, who complained the food was not good, cold, hard, and overcooked. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: Record review of Resident #67's face sheet, dated 08/28/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease also known as COPD (a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction), anxiety (a feeling of fear, dread, and uneasiness), and Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life). Record review of Resident #67's quarterly MDS assessment, dated 08/21/25, indicated Resident #67 usually understood and was usually understood by others. Resident #67's BIMS score was 14, which indicated she was cognitively intact. The MDS indicated Resident #67 required assistance with dressing, personal hygiene, toileting, bathing, bed mobility, transfers, and set-up/supervision for eating. The MDS did not indicate any weight loss in the last sixty days. Record review of Resident #67's physician orders dated 05/16/25 indicated she required a NAS (No Added Salt) diet Regular texture, Regular consistency. Record review of Resident #67's care plan dated 04/21/25 indicated she required an altered diet. The intervention was to serve the diet as ordered. During an interview on 08/25/25 at 11:57 AM, Resident #67 said the food was not good, and sometimes it was served cold. Resident #67 said she reported this to staff but could not recall their names. During an interview on 08/25/25 at 09:40 AM, Resident #87 said the food was not good. Record review of resident council minutes dated 07/21/25 indicated the residents complained about the food not being good, eggs being burnt, corn being cold, and bread being hard. Record review of resident council meeting held by a state surveyor on 08/26/25 at 10:45 AM, indicated 10 residents complained about the food not being good. During an observation and interview on 08/26/25 at 1:22 p.m., a lunch tray was sampled by the Dietary Manager and 5 surveyors. The sample tray consisted of lemon herb chicken, rice, mixed vegetables, pudding, and bread. The Dietary Manager said the tray was not appealing to look at, the lemon herb chicken and rice were too salty, the mixed vegetables were mushy, and the pudding was watery. During an interview on 08/27/25 at 2:17 p.m., the Dietary Manager said she had complaints regarding the food being nasty. She said she had hired at least four cooks in the past year, and the residents complained about them all. She said the cooks only get 2 days of training in the kitchen and felt they needed more training. She said she thought the residents were tired of the same food over and over. She said she had talked with the cooperate dietitian about the menu, and some things were changed. She said she tried to cater to the residents as much as she could. She said she monitored the food and randomly sampled the food, which had not been an issue for her. The Dietary Manager said it was important to ensure the food was palatable and had an appetizing temperature to prevent weight loss or malnutrition. During an interview on 08/28/2025 at 11:15 a.m., CNA C said she had residents to complain about the food. She said they have said it was nasty, no season, and they eat the same things over and over. She said she had let the (unknown) dietary staff know about the residents' complaints. During an interview on 08/28/25 at 2:34 p.m., the DON said the dietary staff was responsible for the palatable and appetizing food. She said she had heard the residents complain about the food not being good but could not recall anything in particular. She said she had not tasted the food. She said that if the residents did not like the food, it could cause them not to eat and lose weight. During an interview on 08/28/25 at 3:13 p.m., the Administrator said she expected the food to be served at the correct temperature, and the food was seasoned and cooked according to the recipe. She said she was aware of some of the residents' complaints from the resident council about the food not being good. She said she had already addressed the issue with the Dietary Manager but may need to come up with a different plan. The Administrator said it was important to ensure food was palatable and had an appetizing temperature because it was their right and to prevent potential weight loss. Record review of the facility's policy titled, Meal Service, dated 04/2022, indicated, Policy: The dining experience will enhance the resident's quality of life and recognize the resident's needs during dining to achieve a nutritional meal. Resident meals will be posted and served at regular times not to exceed 14 hours. Procedure: #1. Residents will be provided with nourishing, palatable, attractive meals that meet the residents' daily nutritional needs.#3. The residents will be able to choose from the daily selections or the always available selections. #8. Proper handwashing practices will be followed according to the guidelines and recommendations provided by the state code.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Residents #30 and Resident #65) and 1 of 3 halls (Hall 100) reviewed for infection control practices. 1. The facility failed to ensure CNA O performed proper hand hygiene and glove changes when providing incontinent care to Resident #30 on 08/25/2025. 2. The facility failed to ensure the Maintenance Supervisor wore PPE when entering Resident #65's room on 08/27/25, who was on contact isolation for C. diff (a highly contagious bacterium that causes diarrhea). The facility failed to ensure the proper disinfectant cleaner was used to clean Resident #65's isolation room with C. diff. 3. The facility failed to ensure linen was not placed on top of the dirty linen barrel on Hall 100 on 08/26/2025. These failures could place residents and staff at risk for cross contamination and the spread of infection.Findings included: 1. Record review of a face sheet dated 08/26/2025 indicated Resident #30 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included other specified diabetes mellitus with diabetic neuropathy (insulin resistance leading to high blood sugars which results in nerve damage cause by prolonged high blood sugar levels) and acquired absence of the left leg below the knee. Record review of Resident #30's Quarterly MDS assessment dated [DATE] indicated he usually understood others and was usually understood by others. The MDS assessment indicated Resident #30 had a BIMS score of 13, which indicated his cognition was intact. The MDS assessment indicated Resident #30 required setup or clean-up assistance with toileting hygiene, showering/bathing, dressing, and personal hygiene. The MDS assessment indicated Resident #30 was occasionally incontinent of urine and frequently incontinent of bowel. Record review of Resident #30's care plan revised 07/15/2025 indicated he had an ADL self-care performance deficit related to his disease processes, immobility, and balance problems. Resident #30's care plan indicated he required limited assistance of one staff for toileting and personal hygiene. Resident #30's care plan indicated he was frequently incontinent of bowel and occasionally of bladder to monitor for incontinence every two hours and as needed and to change promptly. During an observation on 08/25/2025 at 3:34 PM, CNA O provided incontinent care to Resident #30 while he was in bed. CNA O applied gloves and unfastened Resident #30's dirty brief and removed his soiled shorts. CNA O grabbed the wipes container with her dirty gloves and the clean brief and placed them on top of Resident #30's bed. CNA O then wiped Resident #30's front perineal area. Resident #30 had a bowel movement, and CNA O needed more wipes. CNA O grabbed the wipes container with her dirty gloves to get more wipes. CNA O removed Resident #30's dirty brief and put it on top of Resident #30's clean sheet. CNA O grabbed the clean brief with her dirty gloves, then put it down and changed gloves, and put on new gloves. CNA O failed to perform hand hygiene after removing her dirty gloves. CNA then placed the dirty brief in a bag and then applied the clean brief with her dirty gloves. CNA O, with her dirty gloves still on, looked for clean shorts in Resident #30's drawers, applied the clean shorts, and then assisted Resident #30 back to his wheelchair and returned the wipes container to the top of Resident #30's dresser. CNA O removed her dirty gloves, did not perform hand hygiene, grabbed the trash bag with the dirty brief and left Resident #30's room. During an interview on 08/25/2025 at 4:02 PM, CNA O said hand hygiene should be performed before care and before leaving the resident's room. CNA O said gloves should be changed when soiled. CNA O said hand hygiene should be performed in between glove changes. CNA O said she had not adequately performed hand hygiene because it slipped her mind. CNA O said wipes should be removed from the wipes container prior to providing care, and if more wipes are needed gloves should be removed clean ones applied and more wipes removed from the container. CNA O said she had not properly obtained wipes because there was an issue with time. CNA O said touching the wipes container with dirty gloves and returning it to the resident's dresser was considered dirty and could cause cross contamination. CNA O said the dirty brief should be placed in a bag when removed. CNA O said she had not placed it in a bag because there was an issue with not having enough bags. CNA O said placing the dirty brief on top of the clean sheet made the linen soiled and contaminated. CNA O said not changing gloves properly during incontinent care and not performing hand hygiene when required could result in infections. 2. Record review of Resident #65's face sheet, dated 08/28/2025, indicated he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included C. diff, Hyponatremia (a condition that happens when the level of sodium in the blood is lower than the typical range), Chronic Obstructive Pulmonary Disease, also known as COPD (a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction), and anemia (a condition in which there was a lower-than-normal number of red blood cells (RBCs) or hemoglobin in the blood). Record review of Resident #65's Comprehensive MDS assessment dated [DATE] indicated he was usually understood by others and usually understood others. Resident #65's MDS assessment indicated he had a BIMS score of 7, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #65 required partial/moderate assistance with showering/bathing, personal hygiene, and dressing and was dependent on staff for toileting. The MDS assessment indicated Resident #65 was always incontinent of bowel and bladder. Resident #65's MDS assessment indicated he required isolation or quarantine for active infectious disease while a resident at the facility. Record review of Resident #65's Order Summary Report dated 08/27/2025 indicated: Isolation precautions contact and droplet every shift for C. diff and to ensure appropriate signage was posted on the doorway to indicate specific isolation, as well as donning/doffing PPE (refers to the critical procedures of donning (putting on) and doffing (taking off) personal protective equipment (PPE) correctly to ensure worker safety and prevent contamination) stations with a start date of 08/10/2025. Vancomycin HCl 25 milligram/milliliter solution reconstituted, give 5 milliliters by mouth every 6 hours for GI (gastrointestinal) with a start date of 08/20/2025 and end date of 08/28/2025. Record review of Resident #65's care plan, revised 08/20/2025, indicated he was on antibiotics related to C. diff for 10 days with interventions which included to give medication as ordered. Resident #65's care plan did not address isolation precautions for him. Record review of Resident #65's lab of stool re-drawn at the facility on 08/14/25 and received 08/16/25 indicated a positive result of C-Diff. During an observation on 08/25/2025 at 10:40 a.m., Resident #65 had a sign by his doorway that said isolation, along with how to don and doff PPE. The isolation cart was outside his door with gowns, gloves, and masks. Resident #65 was in his bed. During an observation on 08/26/2025 at 08:30 a.m., Resident #65 was in his bed. He said he was aware he was in contact isolation related to his bowels. He said staff usually wore a gown and gloves while in his room. Resident #65 had 2 boxes in his bathroom, 1 lined with a red bag and the other with a yellow bag. The red bag had briefs and other things, and the yellow bag had linen in it. During an observation on 08/26/2025 at 9:02 a.m., the Maintenance Supervisor was in Resident #65's room with gloves on and without a gown. Resident #65 had received his breakfast tray, and it appeared the Maintenance Supervisor was helping him set up his breakfast tray. The Maintenance Supervisor then picked up his clipboard and started writing with the same gloves on. The Maintenance Supervisor then removed his gloves and went into another room without washing his hands or sanitizing his clipboard. During an interview on 08/26/2025 at 11:04 a.m., the Maintenance Supervisor said he did not have to put on a gown while in Resident #65's room. He said he was aware Resident #65 was on contact precautions, but only had to wear gloves because he was not in contact with him. He said he would only need to wear a gown when he was in contact with the resident. He said he believed he helped Resident #65 remove his top to his cup for breakfast this morning, and maybe something else, but could not recall. He said he had on gloves while in Resident #65's room, and when he entered the next room, he applied gloves. He said he usually hand-sanitized with alcohol-based hand rub but could not say if he did or did not when he left Resident #65's room. He said he knew he did not wash his hands with soap and water after leaving Resident #65's room, but could not give a reason why. He said he knew if he did not wash his hands, he could potentially spread germs. During an interview on 08/27/2025 at 11:07 a.m., LVN A said Resident #65 was on contact isolation because he had C-diff. She said that anyone entering his room should wash their hands, apply a gown and gloves, and rewash before leaving the room to prevent the spread of infection. During an observation and interview on 08/28/2025 at 9:12 AM, Housekeeper N said she had been wearing PPE in Resident #65's room. Housekeeper N said she used the same cleaning products for all the rooms, including Resident #65's room. Housekeeper N brought her cleaning products, and they included Ecolab Rapid Multi-Surface disinfectant cleaner and Ecolab acid bathroom cleaner. Housekeeper N said it was important to ensure they were using the correct cleaning products so they would not make anybody sick, and to ensure the disinfectant was doing what it was supposed to do, disinfect. During an interview on 08/28/2025 at 9:45 AM, the Housekeeping Supervisor said he was not aware Resident #65's room required a specific cleaning solution. The Housekeeping Supervisor said he was informed PPE should be worn to clean his room because he was on contact isolation, but he was unaware that Resident #65's room required a specific cleaning disinfectant. The Housekeeping Supervisor said not using the correct cleaning products would not kill the bacteria and could cause spread of the bacteria. During an interview on 08/28/25 at 2:34 p.m., the DON said she expected all staff to follow the guidelines on the sign posted on the door. She said the staff were aware of Resident #65 being on contact precautions by the sign on the door and the setup outside the door. She said staff had to wear PPE (gown or gloves) when they entered Resident #65's room. The DON said she and other department heads made daily rounds to monitor for infection control issues. She said it was important for staff to wear PPE (gown and gloves), wash their hands before entering and exiting Resident #65's room to prevent infection control issues. During an interview on 08/28/25 at 3:13 p.m., the Administrator said staff should wear PPE (gown and gloves) when entering contact isolation rooms. She said the DON was the overseer of infection control. She said that for isolated residents, staff should practice hand hygiene before and after leaving the room to prevent infection. She said they wanted to contain the infection to one area as much as possible. 3. During an observation and interview on 08/26/2025 starting at 8:03 PM, there was a stack of clean bed pads, gowns, and bed linens on top of the dirty linen barrel on Hall 100 in front of the nurse's station. CNA H said she had placed the clean linen on top of the dirty linen barrel. CNA H said she placed it there because they did not have a linen cart. CNA H said the clean linen should not be placed on top of the dirty linen barrel because it would cause the clean linen to be contaminated. During an interview on 08/26/2025 at 8:09 PM, LVN K said the charge nurse was responsible for ensuring the CNAs stored linen properly. LVN K said the clean linen should not be placed on top of the barrels. LVN K said placing them on top of the barrels could contaminate them, and they could get bugs on them from the dirty linen and take it to the residents. LVN K said the CNAs were supposed to place linens in a bag and take them to the residents' rooms. LVN K said she did not notice clean linens had been placed on top of the dirty linen barrel. During an interview on 08/28/2025 at 2:18 PM, the DON said hand hygiene should be performed before providing care, in between glove changes, and before leaving the resident's room. The DON said gloves should be changed when touching anything considered dirty and when gloves were contaminated. The DON said the wipes should be removed from the container prior to the beginning of care. The DON said the CNAs were not supposed to touch the wipes container with their dirty gloves. The DON said when providing care, the dirty brief should be placed in a trash bag. The DON said when touching the dirty brief or gloves become dirty nothing clean should be touched. The DON said the CNAs should remove their dirty gloves, perform hand hygiene and apply new, clean gloves. The DON said not changing gloves when dirty, touching clean items with dirty gloves, and putting the dirty brief on the clean linen could result in cross contamination. The DON said not changing gloves properly and performing hand hygiene when required during incontinent care could result in a urinary tract infection. The DON said linen should be carried directly to the patients' rooms. The DON said the clean linen should not be placed on top of the barrels because it could result in cross contamination. The DON said the Administrator, or the Housekeeping Supervisor were responsible for ensuring the residents rooms were cleaned with the appropriate cleaning solution to disinfect properly. The DON said the Housekeeping Supervisor was in the morning meetings and should have been aware of Resident #65 having C. diff. The DON said not having the proper cleaning solution to disinfect against C. diff could cause reinfecting with the bacteria and it would not clear the bacteria. During an interview on 09/03/2025 at 2:47 PM, the Administrator said hand hygiene was a must, and her expectations were the CNAs used the skills they were trained to use. The Administrator said she expected for the staff to understand the importance of infection control by washing their hands, wearing the proper PPE, and discarding soiled briefs properly. The Administrator said during incontinent care the staff should not go from dirty to clean. The Administrator said this could result in the resident developing infections. The Administrator said touching clean items with dirty gloves resulted in the spread of germs. The Administrator said it was not true that they did not have enough trash bags. The Administrator said the housekeeping department was replacing the trash bags throughout the day. The Administrator said linen should not be sitting out. The Administrator said staff should get the linen they were using for the resident and that resident only. The Administrator said having the linen sitting out was an infection control issue that it should never be left out exposed. The Administrator said there were linen closets at the ends of the hallways, and the staff could go there and to the residents' rooms to take the linen. The Administrator said the Housekeeping Supervisor was responsible for ensuring the correct cleaning disinfectant was used to clean Resident #65's room. The Administrator said the clinical team was responsible for informing the Housekeeping Supervisor when a resident had an organism that required a specific cleaning product. The Administrator said using the correct cleaning products kept the disease from spreading to another residents' room. Record review of an untitled and undated document regarding the EPA numbers for the cleaning disinfectants used in Resident #65's room indicated: 73 Disinfecting Acid Bathroom Cleaner EPA# 1677-246 Neutral Disinfectant Cleaner EPA-registration 47371-1291677 Rapid Multi Surface Disinfectant Cleaner EPA# 1677-272Record review of the following site was accessed on 08/28/2025 and did not indicate the Disinfecting Acid Bathroom Cleaner, Neutral Disinfectant Cleaner, and Rapid Multi Surface Disinfectant Cleaner were effective against C. Diff bacteria: https://www.epa.gov/pesticide-registration/epas-registered-antimicrobial-products-effective-against-clostridioides. https://www3.epa.gov/pesticides/chem_search/ppls/001677-00246-20141028.pdf https://www3.epa.gov/pesticides/chem_search/ppls/001677-00273-20230315.pdf https://ordspub.epa.gov/ords/pesticides/f?p=PPLS:8:11987544152696::NO::P8_PUID,P8_RINUM:151710,47371-129-1677 Record review of the facility's policy titled, Transmission-Based Precautions for Infections, revised 10/24/2022, indicated, 1. Types of transmission-based precautions a. Contact- In addition to standard precautions, use Contact precautions (gown, gloves, mask or faceshield if splashing could occur) for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such and handling environmental surfaces or resident care items.The above includes epidemiologically important organisms (Multidrug-resistant organisms) such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin resistant Enterococcus (VRE), other highly transmissible infections such as Clostridium difficile.Resident's who are infected with or colonized with MDRO's should be in contact isolation when resident has wounds, secretions, or excretions that are unable to be covered or contained, or if ongoing transmission of MDRO's in units or community continue despite attempts to control the spread. b. Droplet- In addition to Standard Precautions, use droplet precautions (gown, gloves, mask) for a resident known or suspected to be infected with microorganisms transmitted by droplets that can be generated by the resident sneezing, coughing, talking, etc. and drop from the air. These incudes bacterial infections such as invasive H. influenza, invasive Neisseria meningitides, Mycoplasma Pneumonia, Streptococcus infection, and some viral infections, including corona virus, adenovirus, in influenza, mumps, and rubella. Spatial separation more than 6 feet and only co-horting residents with same virial infection in the same room with droplet route. If resident must leave room the resident should wear a surgical facemask. 11. Environmental cleaning and disinfection of frequently touched or visibly soiled surfaces in common areas, resident rooms, and at the time of discharge. Record review of the facility's policy titled, Infection Control, revised 10/25/2022, indicated, This communities' infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. Record review of the facility's policy titled, Hand Hygiene, revised 10/24/2022, indicated, Hand Hygiene is used to prevent the spread of pathogens in healthcare settings. Hand hygiene is a general term that describes hand washing using soap and water or the use of an alcohol-based hand rub (ABHR) to destroy harmful pathogens, such as bacteria or viruses, on the hands. 1. You should always perform hand hygiene: When you arrive for work and when you leave for the day Before touching your mouth, nose, or eyes Before applying and after removing personal protective equipment (e.g. gloves, gown, mask, face shield/goggles) Before and after providing any type of care. Record review of the facility's policy titled, Perineal Care, effective 10/01/2021, indicated, To provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached.put on gloves.9. For a male resident: a. Use wipe and apply skin cleansing agent. b. Wash perineal area starting with urethra and working outward.e. Instruct or assist the resident to turn on his side with his upper leg slightly bent, if able. f. Use disposable wipe and apply skin cleansing agent. g. Use wipes on the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. 10. Discard disposable items into designated containers. 11. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable. 13. Place the call light within easy reach of the resident. 14. Clean the bedside stand. 15. Wash and dry your hands thoroughly. Record review of the facility's policy titled, Laundry and Linen processing, dated 10/24/2022, indicated, The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts.

Based on observations, interviews, and record review the facility failed ensure each resident received and the facility provides food that accommodates residents' food preferences for 1 of 24 residents (Resident #6) reviewed for food preferences and the accommodation of resident's meal choices. The facility did not honor Resident #6's preference for fruit punch on 08/25/25 and 08/26/25. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of Resident #6's face sheet, dated 08/28/25, reflected Resident #6 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included cerebral palsy (group of conditions that affect movement and posture). Record review of Resident #6's significant change in status MDS assessment, dated 06/20/25, reflected Resident #6 usually made herself understood, and usually understood others. Resident #6's BIMS score was 15, which indicated her cognition was intact. Resident #6 required setup or clean-up assistance with eating. Resident #6 had not had a 5% weight loss or more in the last month or loss of 10% or more in the last 6 months. Record review of Resident #6's undated comprehensive care plan, reflected Resident #6 was on a NAS diet, regular texture and consistency/therapeutic diet. Resident #6 request fruit punch with lunch and supper. The care plan interventions included Dietary Manager to monitor/discuss food preferences. Record review of Resident #6's order summary report, dated 08/28/25 did not address Resident #6's request for fruit punch at lunch and supper. Record review of the meal ticket dated 08/25/25 and 08/26/25 for Resident #6 reflected beverage preference: fruit punch. During an observation and interview on 08/26/25 at 12:36 p.m., Resident #6 was sitting in the dining room eating her lunch and she stated she wanted some fruit punch. This surveyor went to ask Dietary Aide E about the fruit punch, and she stated they did not have any. The state surveyor told Resident #6 that they did not have any fruit punch, and then she stated they did not have any yesterday (08/25/25). Resident #6 stated it was on her card and she wanted it. The state surveyor looked at her printed tray card ticket and saw her preferred drink was fruit punch. During an interview on 08/26/25 at 2:15 p.m., Dietary Aide E stated the juice machine had been out for a week. Dietary Aide E stated when she tried to pour the juice into the cup, water was coming out instead of the juice. Dietary Aide E stated Resident #6 had asked her one-day last week why she was not receiving fruit punch with her lunch and supper meal. Dietary Aide E stated she did offer Resident #6 lemonade or cranberry juice. Dietary Aide E stated she had reported the issue to the Dietary Manager PRN F and the Dietary Manager. Dietary Manager E stated to the state surveyor she remembered a representative from the juice machine company coming out to check the machine but could not recall the exact date (within the last month), but the machine still did not work afterwards. Dietary Manager E stated it was important for Resident #6's food preference to be followed because it was her right. During an interview on 08/27/25 at 2:36 p.m., the Dietary Manager stated something was wrong with the machine and was informed by Dietary Aide E the fruit punch was coming out watery on 08/26/25. The Dietary Manager stated she expected her or the Dietary Manager PRN F to be notified when staff first noticed the juice was watery. The Dietary Manager stated she monitored once a week by running the machine and tasting the beverages. The Dietary Manager stated it was important for Resident #6's food preference to be followed because it was her right. During a telephone interview on 08/27/25 at 2:54 p.m., a Representative from the juice machine company stated nothing was popping up in his system a service call was made within the last three months. During an interview on 08/27/25 at 3:45 p.m., Dietary Manager PRN F stated she was unaware the fruit punch was coming out as water until 08/27/25 by the Dietary Manager. Dietary Manager PRN F stated she expected staff to notify her as soon as the issue occurred. Dietary Manager PRN F stated it was important for Resident #6's food preference to be followed because it was her preference. During an interview on 08/28/25 at 12:56 p.m., the Regional Director of Clinical Operations stated there was no policy and procedures regarding preferences. During an interview on 08/28/25 at 1:50 p.m., the DON stated if Resident #6 preference was to received fruit punch with meals she should have gotten it. The DON stated the dietary staff were responsible for ensuring the correct juice was placed on the tray. The DON stated when it comes to the floor the nurse was responsible to return if the resident did not receive the correct juice and then if it was not available ask Resident #6 for an alternative option. The DON stated preferences was monitored by the Dietary Manager going and speaking with the residents about their preference. During an interview on 08/28/25 at 3:39 p.m., the Administrator stated her expectation were for the aides to notify the Dietary Manager if the machine was not working correctly. The Administrator stated she expected the staff to provide Resident #6's with the preference she desired. The Administrator stated the Dietary Manager should have contacted the machine representative as soon as the issue was noted. The Administrator stated staff could have even gone to the local store to purchase fruit punch to ensure that her preference was granted. The Administrator stated she monitored preference by engaging with the residents during meals and activities. The Administrator stated it was important for Resident #6's food preference to be followed because it was her right.

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 4 (Resident #99) residents reviewed for quality of care. The facility failed to ensure Resident #99's wound treatment to her right posterior thigh was performed on 08/22/2025. This failure could place residents of risk for not receiving appropriate care and treatment, a decreased quality of life, and wound deterioration.Findings included: Record review of a face sheet dated 08/28/2025 indicated Resident #99 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity (wound of the right lower leg not caused by pressure). Record review of Resident #99's Comprehensive MDS assessment dated [DATE] indicated she was usually understood by others and usually understood others. The MDS assessment indicated Resident #99's BIMS was an 11, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #99 had a surgical wound and required surgical wound care. Record review of Resident #99's Order Summary Report dated 08/27/2025 indicated right posterior thigh cleanse with Vashe (wound cleanser), pat dry, apply wound VAC cut foam to fit in wound bed, secure in place with drape, cut small hole in drape over foam, place port over hole, connect to wound VAC at 125 mmhg continuous one time a day every Monday, Wednesday, and Friday with an order date of 08/22/2025. Record review of Resident #99's care plan revised 08/25/2025 indicated she required enhanced barrier precautions due to a chronic wound or skin opening that required a dressing change. Resident #99's care plan did not further address her wound or wound care treatment. During an observation and interview on 08/25/2025 at 9:24 AM, Resident #99 was in her bed with a dressing on her right thigh dated 08/20/2025 attached to a wound VAC set at 125 mmhg. Resident #99 said her last wound treatment was at the hospital that the wound dressing had not been changed while she was at the facility. Resident #99 said she did not remember when they were doing the wound treatments at the hospital or the frequency of the treatments. During an interview on 08/28/2025 at 8:14 AM, the Treatment Nurse said Resident #99 admitted to the facility with the wound VAC on Thursday, 08/21/2025. The Treatment Nurse said she had not done the wound care on Friday, 08/22/2025 because when she assessed Resident #99, she thought the dressing was dated 08/21/2025. The Treatment Nurse said it was important to ensure wound care treatments were completed as ordered so there was no delay in care, and the wound did not decline. During an interview on 08/28/2025 at 2:10 PM, the DON said the Treatment Nurse was responsible for completing the treatments. The DON said not performing wound care treatments as ordered could delay the healing of the wound. During an interview on 08/28/2025 at 2:37 PM, the Administrator said she expected for the wound treatments to be completed as ordered. The Administrator said the treatment nurse was responsible for completing the wound care treatments. The Administrator said not completing the wound treatments could be a decline in care and could cause an infection. Record review of the facility's policy titled, Skin Management: Prevention and Treatment of Wounds, revised 10/06/2022, indicated, The purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds. The policy did not further address providing wound care treatments.

Based on interview and record review the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days for 1 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #9). The facility failed to ensure Resident #9's PRN Ativan (antianxiety medication) was discontinued within 14 days or reevaluated by the prescribing practitioner. This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.Findings included: Record review of Resident #9's face sheet dated 08/28/25, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #9 had diagnoses of Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), diabetes mellitus type 2 (chronic metabolic disorder characterized by high blood sugar levels), and dysphagia (difficulty swallowing). Record review of Resident #9's significant change in status MDS assessment dated [DATE], indicated she was usually understood and usually understood others. Resident #9's BIMS score of 3, which indicated her cognition was severely impaired. The MDS assessment did not reflect Resident #9 had received an antianxiety medication within the 7-day look back period. Record review of Resident #9's comprehensive care plan revised 07/10/25, indicated Resident #9 received an antihistamine related to her anxiety. The care plan interventions indicated to administer antihistamine medications as ordered by the physician and to monitor for side effects and effectiveness every shift. Record review of Resident #9's order summary report dated 08/28/25, indicated she had an order for Ativan 0.5mg one tablet every 6 hours as needed for anxiety with a start date of 07/29/25. The order did not have an end date. Record review of Resident #9's nurse MAR dated 08/01/25-08/31/25, indicated Resident #9 had received one tablet of Ativan 0.5mg on the following days:*08/12/25 at 3:20 PM*08/13/25 at 4:00 PM*08/20/25 at 6:45 AM Record review of the psychotropic and sedative/hypnotic utilization by resident report dated 08/14/25, indicated Resident #9 was receiving Ativan 0.5mg every 6 hours PRN anxiety. The report indicated the need for a time frame from hospice. During an interview on 08/28/25 at 12:57 PM, the DON said when a resident was admitted to hospice and the PRN Ativan order does not have a stop date, they reached out to the hospice company for clarification. She said the ADON and herself review psychotropic medications every Wednesday as well as the pharmacy recommendations. She said she was unsure of how the medication was missed. She said the pharmacy recommendations did not indicate Resident #9 needed a time frame for her PRN anxiety medication. The DON reviewed Resident #9's EMR and said she could not find a hospice note to indicate the need for continued use of PRN Ativan. During an interview on 08/28/25 at 1:16 PM, the Administrator said the hospice companies usually wrote a note which indicated the reason for the extended use of the medication. The Administrator said after that the medication was reassessed for continued use. She said failure to reassess the need for the continued medication could place the resident at risk for adverse reactions. She said the Director of Nurses was over the clinical team was responsible for ensuring the PRN psychotropic medications included a stop date. During an interview on 08/28/25 at 1:44 PM, the Pharmacist said PRN psychotropic medications were to be written for 14 days per CMS guidelines. She said the facility reached out to hospice at day 14 to prompt them to provide the documentation for extended use. She said she reviewed the pharmacy recommendations for the month of August 2025, and the nursing recommendation did not populate for Resident #9's recommendation for needing a time frame from hospice. Therefore, the facility was unaware of needing a stop date. The Pharmacist said it was the hospice responsibility to include the stop date when the orders were written. Record review of the facility's policy Psychotropic Medication Review dated 04/2020, indicated .IDT will emphasize the importance of seeking an appropriate dose and duration of each psychotropic medication, with careful assessment as to whether the medication is necessary and pharmacologically appropriate. 1. The community will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications, to include regular review of continued need, appropriate dosage, side effects, risk and/or benefits. Monitors psychotropic drug use to ensure that medications are not used in excessive doses or for excessive duration.

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 1 resident (Resident #94) reviewed for MDS assessment accuracy. The facility incorrectly coded Resident #94's discharge MDS assessment dated [DATE] reflected Resident #94 was discharged to a short-term general hospital when the resident was discharged home. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #94's face sheet, dated 08/28/25, reflected Resident #94 was a [AGE] year-old male readmitted to the facility om 05/29/25 with a diagnosis which included end stage renal failure (a condition in which the kidneys lose the ability to remove waste and balance fluids). Record review of Resident #94's discharge MDS assessment, dated 06/13/25, reflected in Section A2105 (discharge status) coding of 04 which means discharge to short term general hospital. Record review of Resident #94's physician Discharge summary, dated [DATE], reflected Resident #94 was dc' d home with medications and belonging. During an interview and record review on 08/28/25 at 11:28 a.m., the MDS Coordinator stated she was responsible for Resident #94's discharge MDS assessment. After reviewing Resident #94's electronic medical records, the MDS Coordinator stated the discharge assessment should have been coded discharge to home/community. The MDS Coordinator stated it was important to ensure the assessment was coded correctly to see whether the resident was dc' d home/community, hospital or another facility. The MDS Coordinator stated there was no policy and procedures regarding MDS assessment accuracy. The MDS Coordinator stated the facility followed the RAI manual. During a telephone interview on 08/28/25 at 12:45 p.m., the Regional Clinical Reimbursement Coordinator stated the MDS Coordinator should have coded Resident #94's discharge assessment to home/community. The Regional Clinical Reimbursement Coordinator stated he generated a report every 30 days and certain things were monitored on the discharge assessment such as if the resident was going to return or not when they were sent out to the hospital but not the discharge status. The Regional Clinical Reimbursement Coordinator stated it was important to ensure the correct discharge status was completed to see where the resident went to and for their own statistics. During an interview on 08/28/25 at 1:50 p.m., the DON stated she expected the correct discharge status was completed on the discharge assessment. The DON stated the MDS Coordinator was responsible for ensuring the correct discharge status was completed. The DON stated it was important to ensure the correct discharge status was completed for accuracy. During an interview on 08/28/25 at 3:39 p.m., the Administrator stated she expected Resident #94's discharge assessment to be coded correctly. The Administrator stated the MDS Coordinator was responsible for ensuring the correct discharge status was coded. The Administrator stated the [NAME] Clinical Reimbursement Coordinator was responsible for monitoring. The Administrator stated there was no harm with not having the correct discharge status. Record review of the Resident Assessment Instrument 3.0 User's Manual, last revised October 2024, reflected. Item Rationale . This item documents the location to which the resident is being discharged at the time of discharge. Coding Instructions. Code 01, Home/Community: if the resident was discharged to a private home, apartment, board and care, assisted living facility, group home, transitional living, or adult foster care. A community residential setting is defined as any house, condominium, or apartment in the community, whether owned by the resident or another person; retirement communities; or independent housing for the elderly.

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care for 1 of 6 residents (Resident #99) reviewed for baseline care plans. The facility failed to develop a baseline care plan that addressed Resident #99's use of a wound VAC (machine that promotes wound healing by applying negative pressure to the wound area by helping to draw the edges together and remove excess fluid) to her right thigh wound. This failure could place residents at risk of not receiving care and services to meet their needs.Findings included: Record review of a face sheet dated 08/28/2025 indicated Resident #99 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity (wound of the right lower leg not caused by pressure). Record review of Resident #99's Comprehensive MDS assessment dated [DATE] indicated she was usually understood by others and usually understood others. The MDS assessment indicated Resident #99's BIMS was an 11, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #99 had a surgical wound and required surgical wound care. Record review of Resident #99's Order Summary Report dated 08/27/2025 indicated right posterior thigh cleanse with Vashe (wound cleanser), pat dry, apply wound VAC cut foam to fit in wound bed, secure in place with drape, cut small hole in drape over foam, place port over hole, connect to wound VAC at 125 mmhg continuous one time a day every Monday, Wednesday, and Friday with an order date of 08/22/2025. Record review of Resident #99's Baseline Care Plan dated 08/23/2025 did not indicate Resident #99 required a wound VAC. During an observation on 08/25/2025 at 9:24 AM, Resident #99 was in her bed with a dressing on her right thigh attached to a wound VAC set at 125 mmhg. During an interview on 08/25/2025 at 2:13 PM, the DON said the baseline care plan was completed by the nurses, the social worker, dietary, and then she reviewed the baseline care plan and completed the summary. The DON said Resident #99's use of a wound VAC should have been included in her baseline care plan. The DON said she thought Resident #99's wound VAC was on the baseline care plan. The DON said the wound VAC should be included on the baseline care plan for communication, and that the baseline care plan was the resident's plan of care. During an interview on 08/25/2025 at 2:38 PM, the Administrator said the baseline care plan should include components of the residents' needs. The Administrator said Resident #99's use of a wound VAC should have been included in her baseline care plan. The Administrator said the DON was responsible for ensuring the baseline care plan included the residents' needs. The Administrator said it was important for a wound VAC to be included in the baseline care plan because it was part of the plan of care and for continuity of care. Record review of the facility's policy titled, Baseline Care Plan, dated 11/01/2019, indicated, A baseline care plan is required to be completed within 48 hours of admission The baseline care plan must include.Physician Orders.The facility must provide the resident and their representative with a summary of the baseline care plan to include as a minimum. any services and treatments administered by the facility and personnel acting on behalf of the facility.

Based on observation, interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 24 residents (Resident #8 and Resident #9) reviewed for care plans. 1. The facility failed to ensure Resident #8's care plan included her fall on 04/03/25 and interventions.2. The facility failed to ensure Resident #9's care plan included the antianxiety medication prescribed for her anxiety. These failures could have placed residents at risk for not having their needs met. Findings included: 1.Record review of Resident #8's face sheet dated 09/03/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with diagnoses history of falls, dementia (group of conditions that cause a decline in cognitive abilities), anxiety, and high blood pressure. Record review of Resident #8's annual MDS dated [DATE] indicated she usually understood others and was usually understood by others. The MDS also indicated she had a BIMS score of 6 which meant she had severe cognitive impairment. The MDS also indicated she required moderate assistance from staff for bed mobility, transfers, bathing, and she required setup for eating. Record review of Resident #8's care plan revised 08/25/25 indicated she was at risk for falls and had a history of falls but had no mention of her actual fall on 04/03/25. The care plan did not indicate any interventions in place after the fall on 04/03/25. Record review of Resident #8's fall dated 04/03/25 indicated she was in the dining room and was attempting to tie her shoe and fell from her wheelchair to the floor. During an observation and interview on 08/28/2025 at 2:47 PM the MDS nurse said she was responsible for care plans and the management nurses (ADON, DON, and MDS nurse) normally resolved the care plans over unknown time. She said if it was an acute care plan, the charge nurse that was in the dining room at the time should have updated the care plan after the fall and then the management nurses should have discussed the fall in the standards of care meeting they have weekly on the following Wednesday (04/09/25) to ensure it was care planned. The MDS nurse and ADON reviewed the EMR for Resident #8 to find the care plan was never updated. The MDS nurse said the failure placed a risk for the Resident #8 falling again. During an interview on 08/28/2025 at 4:13 PM the DON said she expected Resident #8's fall and interventions to be included in her care plan. She said when the nurses notified her of falls, she would normally discuss what measures to put in place for residents and the nurse should have should updated the care plan. The DON said the management nurses then discussed falls in the morning meeting to ensure it was completed but she guessed Resident #8's fall was missed. The DON said the failure placed a risk for Resident #8 having more falls. During an interview on 08/28/2025 at 4:29 PM the Administrator said she expected the care plan to be updated to include intervention and goals after Resident #8's fall. She said the MDS was responsible for ensuring the care plans were updated. The Administrator said the failure placed risk for falls happening again. 2. Record review of Resident #9's face sheet dated 08/28/25, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #9 had diagnoses of Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), diabetes mellitus type 2 (chronic metabolic disorder characterized by high blood sugar levels), and dysphagia (difficulty swallowing). Record review of Resident #9's significant change in status MDS assessment dated [DATE], indicated she was usually understood and usually understood others. Resident #9's had a BIMS score of 3, which indicated her cognition was severely impaired. The MDS assessment did not reflect Resident #9 had received an antianxiety medication within the 7-day look back period. Record review of Resident #9's comprehensive care plan revised 07/10/25, indicated Resident #9 received an antihistamine related to her anxiety. The care plan interventions indicated to administer antihistamine medications as ordered by the physician and to monitor for side effects and effectiveness every shift. The care plan did not reflect Resident #9 received Ativan PRN for anxiety. Record review of Resident #9's order audit report dated 08/28/25, indicated the order for hydroxyzine 25mg one tablet by mouth every 8 hours as needed was discontinued by the DON on 07/15/25. Record review of Resident #9's order summary report dated 08/28/25, indicated she had an order for Ativan 0.5mg one tablet every 6 hours as needed for anxiety with a start date of 07/29/25. During an interview on 08/28/25 at 12:57 PM, the DON said expected the care plans to be updated with any changes. The DON said the care plan was the plan of care for the resident and failure to update them placed the resident risk for staff to be unaware of how to care for the resident. The DON said the MDS nurse was responsible for ensuring the care plans were updated. During an interview on 08/28/25 at 1:16 PM, the Administrator said she expected the care plans to be revised and updated with any changes. She said the care plan was geared to the resident with the expectations and outcomes. The Administrator said the MDS Coordinator was responsible for revising the care plans. She said failure to revise the resident's care plan placed them at risk for not abiding by their wishes and quality of life. Record review of the facility policy Comprehensive Care Plan last revised 04/25/2021 indicated Policy Every resident will have an individualized interdisciplinary plan of care in place. A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of Admission. The Interdisciplinary Team will continue to develop the plan in conjunction with the RAI (MOS 3.0) and CAAS, completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after Admission. The Care Plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process. The resident's Care Plan will include participation from residents' representatives, external partners PASRR, Hospice, Therapy, Clinicians and not as all-inclusive. Procedure. 5. The Interdisciplinary Team will review the healthcare practitioner's notes and orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a Comprehensive Care Plan to meet the residents' immediate care needs including but not limited to.h. Fall Prevention.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 24 residents (Residents #63) reviewed for ADL care.The facility failed to ensure Resident #63 was assisted with her personal hygiene to ensure she was free of body odor and had a clean gown on 08/25/2025. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.Findings included: Record review of a face sheet dated 08/28/2025 indicated Resident #63 was a [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side (weakness and paralysis to the right side of the body caused by a medical condition that affects the blood vessels and circulation of the brain) and aphasia (communication disorder due to damage to the areas of the brain responsible for language). Record review of Resident #63's Quarterly MDS assessment dated [DATE] indicated she sometimes understood and was usually understood by others. The MDS assessment indicated Resident #63 had a BIMS score of 0, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #63 required partial/moderate assistance with showering/bathing, dressing, and personal hygiene. Record review of Resident #63's care plan revised 08/26/2025 indicated she had an ADL self-care performance deficit related to disease processes a stroke. Resident #63's care plan indicated she required extensive assistance by one staff with bathing/showering and personal hygiene three times a week and as necessary. Record review of Resident #63's bathing task record for the month of August 2025 indicated she received her baths as scheduled on Monday, Wednesday, and Friday for the month of August 2025. During an observation and interview on 08/25/2025 at 10:43 AM, Resident #63 was in her bed, her gown had stains on it and white specks, and she had a strong, musty odor. Resident #63 was only able to answer yes or no questions due to her aphasia. When asked if she was receiving her baths, she replied, no and grabbed her gown and started pointing at it. When asked if staff was changing her clothes every day, she replied, no. During an interview on 08/27/2025 at 2:18 PM, CNA L said Resident #63 received bed baths on Monday, Wednesday, and Friday. CNA L said Resident #63 did not refuse any of her baths that she was ready to get them. CNA L said she probably missed some of Resident #63's baths because she had been at the facility for about a month, and she was not familiar with the bathing schedule. CNA L said she had worked over the weekend and changed Resident #63's clothes, but she was not sure if the night shift had changed her. CNA L said it was important to keep up the resident's hygiene to make sure they were getting taken care of properly. During an interview on 08/27/2025 at 2:42 PM, LVN M said she was not aware of Resident #63 missing any bed baths, and she had not noticed any hygiene issues with her. LVN M said the CNAs were responsible for providing bathing and ADL care. LVN M said it was important for the residents to be clean for infection control. During an interview on 08/28/2025 at 2:15 PM, the DON said the charge nurses were responsible for ensuring the residents received proper ADL care. The DON said she made rounds randomly to check on the residents ADL care, and she had not noticed any issues. The DON said it was important for the residents to receive proper ADL care for their personal hygiene, upkeep, and because it was their right to be clean. During an interview on 08/28/2025 at 2:41 PM, the Administrator said she expected for the residents to be bathed on their day or as requested, and she had not had any complaints about the residents not being clean. The Administrator said the staff should assist the residents with ADL care when it was not their bath day. The Administrator said it was important for infection control and to prevent the breakdown of skin. During an interview on 08/28/2025 at 12:29 PM, the DON said the facility did not have a policy on ADLs.

Based on observation, interview, and record review the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 24 residents (Resident #87) reviewed for reasonable accommodations. The facility failed to ensure Resident #87's call light was within reach while in bed on 08/25/2025. This failure could place residents at risk for a delay in assistance and a decreased quality of life.Findings include: Record review of Resident #87's face sheet dated 08/28/24, indicated a [AGE] year-old female who readmitted to the facility on [DATE]. Resident #87 had diagnoses of muscle weakness, lack of coordination, difficulty walking, and abnormalities of gait and mobility. Record review of Resident #87's quarterly MDS assessment dated [DATE], indicated she was usually understood and usually understood others. The MDS assessment indicated Resident #87 had a BIMS score of 11, which indicated her cognition was moderately impaired. Resident #87 required supervision or touching assistance with toileting, upper body dressing, and putting on/taking off footwear. Resident #87 required partial/moderate assistance for showering, lower body dressing and personal hygiene. Resident had not had any falls. Record review of Resident #87's care plan revised on 05/10/24, indicated Resident #87 was at risk for increased falls and fractures as evidenced by unsteady gait. The care plan interventions indicated to ensure call light was in reach and answered promptly. During an observation and interview on 08/25/25 at 09:40 AM Resident #87 was in her bed. She did not have her call light within reach. The call light was noted to be hanging on the wall. Resident #87 said she did not know where her call light was but would have liked one. She said when she needed assistance, she would go to the nurse's station and ask for help. During an observation and interview on 08/25/25 at 9:51 AM, CNA R said she usually worked on Resident #87's hall on the 6:00 AM- 6:00PM shift. CNA R entered Resident #87's where she found Resident #87's call light hanging on the wall. CNA R said Resident #87 had her call light within reach that morning. CNA R said she took Resident #87 to the shower and must have accidently put the call light up. CNA R said she was responsible for ensuring the call lights were within reach and failure to do so could cause the resident to not be able to call for assistance. CNA R said she made rounds on the residents frequently so she would have been aware if she was to need something. During an interview on 08/28/25 at 12:57 PM, the DON said she expected the call lights to be answered in a timely manner and be within reach of the resident. She said they ensured call lights were within reach by conducting care rounds each morning and during clinical rounds. She said CNAs and nurses were also responsible for ensuring the call lights were within reach. The DON said failure to provide the resident's call light within reach could cause the resident to have to wait a long time to receive assistance. During an interview on 08/28/25 at 1:16 PM, the Administrator said she expected the call lights to be answered in a timely manner and be within reach. She said failure to have the call light within reach could cause the resident to not be able to express their needs or concerns to the staff. The Administrator said everyone was responsible for answering the call lights. She said the CNAs were responsible for ensuring the call lights were within reach after they provided care to the resident. Record review of the facility's policy Bedrooms revised May 2017, indicated .6. All resident rooms are equipped with a resident call system that allows residents to call for staff assistance. Calls are directed to either a staff member or to a centralized work area.

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 residents (Resident #67) reviewed for respiratory care. The facility failed to ensure Resident #67's oxygen was set at 3 liters per nasal cannula as ordered on 08/28/25. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.Findings included: Record review of Resident #67's face sheet, dated 08/28/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease also known as COPD (a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction), anxiety (a feeling of fear, dread, and uneasiness), and Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life). Record review of Resident #67's quarterly MDS assessment, dated 08/21/25, indicated Resident #67 usually understood and was usually understood by others. Resident #67's BIMS score was 14, which indicated she was cognitively intact. The MDS indicated Resident #67 required assistance with dressing, personal hygiene, toileting, bathing, bed mobility, transfers, and set-up/supervision for eating. The MDS during the 7-day look-back period indicated Resident #67 was receiving oxygen. Record review of Resident #67's physician orders dated 04/17/25 indicated oxygen at 3 liters per minute via nasal cannula continuously. Record review of Resident #67's care plan dated 04/21/25 indicated she required oxygen. The intervention was for staff to apply oxygen at 3 liters per minute via nasal cannula, continuously, and change oxygen tubing as needed. During an observation and interview on 08/28/25 at 11:00 a.m., Resident #67 was sitting on the side of her bed, wearing oxygen at 2.5 liters per nasal cannula. Resident #67 said her oxygen should be set at 3 liters. During an observation and interview on 08/28/25 at 11:09 a.m., LVN B verified that Resident #67 was receiving oxygen at 2.5 liters per nasal cannula. She said it was her responsibility to ensure the oxygen was set at the correct rate. She said she had not checked Resident #67's oxygen before the state surveyor's intervention. She said it was important to ensure the oxygen was at the correct rate ordered to help maintain an effective airway. During an interview on 08/28/25 at 2:34 p.m., the DON said the charge nurses were responsible for ensuring the oxygen was set at the ordered rate. She said they had monitoring in place with an assigned department head on their focus rounds, responsible for ensuring the oxygen was set at the correct rate. She said if the oxygen rate were too low, it could cause respiratory distress. During an interview on 08/28/25 at 3:13 p.m., the Administrator said if a resident had an order for oxygen, it should be applied. She said the nurses were responsible for ensuring the oxygen was set at the ordered rate, and nurse managers were the overseers. She said failure to follow the oxygen order could cause respiratory issues. Record review of facility policy titled, Oxygen Administration, revised 4/2021, indicated, Policy: It is the policy of this community to ensure all oxygen administration is conducted in a safe manner. Procedure #1. Verify there is an order for Oxygen administration to include: a. Method of Delivery, b. Flow Rate, c. Oxygen saturation parameters if indicated. #3. Assess the resident's respiratory status. # 4e Post NO SMOKING sign on the outside of the door to the resident's room. 5. Check the tubing connected to the oxygen concentrator to ensure that it is free of kinks. 6e Start Oxygen flow at the rate as ordered.

Based on interview and record review, the facility failed to ensure dialysis services were provided consistently with professional standards of practice for 1 of 2 resident reviewed for dialysis services. (Resident #7) The facility did not provide ongoing assessments after Resident #7's dialysis treatments and did not keep ongoing communication with the dialysis facility. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.Findings included: Record review of Resident #7's face sheet dated 08/28/25 indicated he was an [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses of end stage renal disease (disease in which the kidneys lose ability to remove waste and balance fluids), dementia (a group of conditions that cause a decline in cognitive abilities, such as memory), high blood pressure, and heart failure. Record review of Resident #7's quarterly MDS dated [DATE] indicated he was usually understood and usually made himself understood by others. The MDS also indicated he had a BIMS score of 4 which meant he had severe cognitive impairment. The MDS also indicated he received dialysis treatment while in the facility. Record review of Resident #7's care plan revised on 07/15/25 indicated he required dialysis three times a week for renal failure with interventions for staff to monitor signs and symptoms of depression, PRN any signs and symptoms of infection to access site: Redness, Swelling, warmth or drainage, PRN for signs and symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor (elasticity of the skin that measures dehydration), oral mucosa (how moist the inside of the mouth is), changes in heart and lung sounds, signs and symptoms of the following: bleeding, hemorrhage (bleeding out), bacteremia (blood poisoning), septic shock (infection causing organ failure), document, and report any changes to the medical doctor. Record review of Resident #7's order summary report dated 08/28/25 indicated he had an order for: 1) Dialysis Tuesday/Thursday/Saturday at dialysis center and address @3:10 PM every shift coordinate medication administration times on dialysis days with a start date of 11/24/24 and no stop date. Record review of the medical record for Resident #7 indicated there were no documented before and after assessments and ongoing communication with the dialysis service for Resident #7 on the following dates she had dialysis services provided:07/05/2507/08/2507/12/2507/15/2507/22/2508/05/2508/16/2508/23/25 During an interview on 08/28/25 at 4:20 PM, the DON said her expectation was for the communication to be completed on each day a resident attends dialysis. She said her expectation was now going to be to bring the communication sheets to her from the weekend to ensure they were completed. She said the failure placed a risk of missing communication with the dialysis that ensured the resident was stable and had no change of conditions after dialysis was completed. During an interview on 08/28/2025 at 4:23 PM, the Administration said her expectation was for the nurses to have assessed the resident and documented the information on the communication form and turned it into the medical records on dialysis days. She said if the facility did not receive the form from dialysis, she expected the nurse to have called the dialysis company and retrieved the information to have been available in the facility. The Administrator said the failure placed a risk for the nurse missing a change in condition which could have caused Resident #7 to have been in harm's way and the failure also caused the medical record to be incomplete. Record review of the facility policy Dialysis General Guidelines and Management, dated 04/2021, indicated:PolicyIt is the policy of the facility community that residents in need of dialysis services will receive services as per physician orders and will be monitored accordingly. NURSING INTERVENTION 1. Avoid wearing constrictive clothing of limb containing access.3. Prior to dialysis treatments assess vitals, edema, access site, mental status, complaints of pain/discomfort, blood sugar (if ordered), and administer meds as directed by the dialysis center.

Based on interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 10 residents (Resident #91) and 1 of 2 medication rooms reviewed for pharmacy services. 1. The facility failed to reorder Resident #91's hydrocodone 7.5/325mg (pain medication) tablet timely resulting in Resident #91 having 3 days without medication. 2. The facility did not ensure the plastic bag of Lorazepam 2mg/ml (antianxiety medication) syringes in the station 2 refrigerator we reconciled. These failures could place the residents at risk of not having medications available for use, drug diversion, not receiving their medications as ordered, and exacerbation of their disease processes. Findings included: 1.Record review of Resident #91's face sheet dated 08/27/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses diabetes mellitus (disease in which the body has too much sugar in the blood), pain unspecified, anxiety, and high blood pressure. Record review of Resident #91's quarterly MDS dated [DATE] indicated she usually made herself understood and was usually able to understand others. The MDS also indicted she had a BIMS score of 10 which meant she had moderate cognitive impairment. The MDS also indicated that Resident #91's pain rarely limited her day to day activities. Record review of Resident #91's care plan dated 07/10/25 indicated she had a potential for pain related to muscle spasms with interventions to assess characteristics of pain: Location, Severity, on a scale of 1-10, type and frequency, discuss with resident factors that precipitate pain and what may reduce it, administer pain medications as ordered, and discuss with resident the need to request pain medications before pain becomes severe. Record review of Resident #91's order summary report dated 08/27/25 indicated she had an order for:1)Monitoring of pain-if pain is noted, chart in nurses notes the interventions/treatments used and the effectiveness - Intervention Codes: 0 - none, 1 -medication, 2 - re-position, 3 - heat, 4 - cold, 5 - gentle range of motion, 6 - other (see nurses note) every shift with a start date of 06/05/2024 and no end date. 2)Hydrocodone-Acetaminophen Tablet 7.5-325 MG Give 1 tablet by mouth every 12 hours as needed for pain with a start date of 01/12/2025 and no end date. Record review of Resident #91's licensed nurse MAR for 08/01/25-08/31/25 indicated resident did not have any Hydrocodone 7.5/325mg tablets administered on 08/16/25 or 08/17/25 and her pain levels were documented as 0 on 08/16/25 and 08/17/25. Record review of Resident #91's narcotic count sheet for hydrocodone 7.5/325mg tablets received 06/17/25 indicated she took the medication nightly, and her last dose received was 08/15/2025 at 7:53 PM. Record review of Resident #91's narcotic count sheet for hydrocodone 7.5/325mg tablets received 08/18/25 indicated she received the first dose on 08/18/25 at 8:30 PM. During an interview on 08/25/2025 at 3:54 PM, Resident #91 was sitting in her room on the bed and did not appear to be in any pain. She said the facility ran out of her pain medication for 3 days around 08/16/25 and she did not receive the medication until the following Monday 08/18/25. She said she was in pain, but the nurse gave her Tylenol as needed that helped decrease her pain level and called the doctor and ordered an antianxiety medication to help with her sleeping. She said she had been getting her hydrocodone as needed since the incident. During an interview on 08/28/2025 at 4:05 PM, the DON said she expected the nurses and the medication aides to ensure the residents had their medications and they should have notified the doctor in enough time to ensure the medication did not run out. The DON said she also expected the Hydrocodone 7.5/325mg tablets to be followed up on by the nurses. She said the failure placed a risk for Resident #91 to have increased pain. During an interview on 08/28/2025 at 4:31 PM, the Administrator said her expectation was for the resident to have the medication changed to routine since she was taking like routine. The Administrator said the nurses or medication aides should have been calling to request refill within 6-7 doses remaining to ensure the medication would have been in the facility when Resident #91 needed it. The Administrator said the failure placed a risk for Resident #91 having increased pain, but the facility did have breakthrough medication Tylenol and administered it and it was effective. 2. During an observation and interview on 08/26/25 at 3:54 PM, the station 2 medication room refrigerator contain a plastic bag of 6 Lorazepam 2mg/ml syringes with no narcotic count sheet in the narcotic book. LVN A said the medication was discontinued on 08/20/25 but the medication was not counted today because she had been off and did not know the medication was in there. During an observation and interview on 08/28/25 at 1:31 PM, LVN S found the plastic bag of 6 Lorazepam 2mg/ml syringes in the station 2 medication room refrigerator and said she did not count the medication when she completed her narcotic count because she did not know there was medication in the refrigerator. She said the failure placed a risk for the medication to be lost or stolen. During an interview on 08/28/2025 at 4:11 PM, the DON said she expected the nurses to count the narcotics daily to ensure accuracy. The DON said when the medications were discontinued the nurse should have given them to her to record and lock in her box. She said the failure placed a risk for a medication error or misappropriation. During an interview on 08/28/2025 at 4:43 PM the Administrator said her expectation was for all narcotics to be accounted for and signed off. She said the failure placed a risk for the medication to leave the facility and misappropriation of narcotics. During an interview on 08/28/25 at 1:40 PM the corporate nurse said the facility did not have a policy on controlled medications.

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 24 residents (Resident #23) and 1 of 10 medication carts (Station 1 Medication Cart) reviewed for drugs and biologicals. 1. The facility failed to ensure MA P secured the Station 1 Medication Cart, when it was not in use and unattended on 08/25/2025. 2. The facility failed to ensure Resident #23 did not have a container of zinc oxide, a package of hydrocortisone cream, and a 30-milliliter medicine cup filled with white cream in his room on the bedside table. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.Findings included: 1. During an observation on 08/25/2025 starting at 1:18 PM, the Station 1 Medication Cart was unlocked an unattended on the hall. There were residents nearby the unlocked medication cart, and multiple staff walked by it. MA P was observed coming down the hallway to the Station 1 Medication Cart. MA P said it was her medication cart, and the last time she left she thought she had locked it. MA P said leaving the Station 1 Medication Cart unlocked was an accident. MA P said the medication cart should be locked every time she left it. MA P said it was important for the medication carts to be locked when unattended so the residents could not get in the medication cart. MA P said leaving the medication cart unlocked could result in missing medications because somebody could take them. During an interview on 08/28/2025 at 2:31 PM, the DON said the person who was responsible for the medication cart should ensure it was locked. The DON said the medication carts should be locked anytime the staff was away from it. The DON said she monitored by making rounds in the hallways throughout the day. The DON said if the medication cart was left unlocked someone could go into the medication cart and take medications. During an interview on 08/28/2025 3:03 PM, the Administrator said the medication carts should be locked at all times when not in use because they could have a resident come by and have access to the medication cart. The Administrator said nobody should have access to the medications that were on the medication carts. The Administrator said the person responsible for the medication cart should be ensuring it remained locked when not in use, and the DON and ADON should be monitoring. 2. Record review of Resident #23's face sheet dated 08/28/25 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the diagnoses Guillain-Barre syndrome (a condition in which the autoimmune system attacks the nerves), acute kidney failure, systemic sclerosis (a rare disease that causes the body to produce too much collagen causing contractures ad skin thickening), and need for assistance with personal care. Record review of Resident #23's quarterly MDS dated [DATE] indicated he was usually able to make himself understood and usually understood others. The MDS also indicate he had a BIMS score of 13 which meant he was cognitively intact. The MDS also indicated he required moderate assistance from staff for toileting, bed mobility and bathing and required setup for eating. The MDS also indicated he was incontinent of bowel and bladder. Record review of Resident #23's care plan revised 07/28/25 indicated he was incontinent of bowel and bladder, and he was at risk for skin breakdown with interventions for the staff to monitor every 2 hours, promptly change, and apply protective skin barrier. Record review of Resident #23's order summary report dated 08/28/25 indicated he had an order for: 1) Cream-SMBC (cream that contains hydrocortisone, nystatin, zinc oxide) 1/1/1 cream apply to buttock topically three times a day for excoriation of the buttock until healed with a start date of 08/26/25 and no end date. 2) Hydrocortisone External Cream 0.5 % (Hydrocortisone (Topical)) Apply to bilat antecubital topically four times a day for rash with a start date of 06/12/25 and no end date. The order summary did not indicate an order for zinc oxide barrier cream. During an observation and interview on 08/25/2025 at 10:15 AM, Resident #23 was sitting in his bed and had a 30-milliliter medication cup filled with white cream and a package of hydrocortisone cream on his bedside table. Resident #23 said the nurse placed the cream on his bedside table and left for the resident to apply it. Resident #23 said they left the white cream for his ass and a package of hydrocortisone cream he said was for the rash on arm. During an observation and interview on 08/27/2025 at 12:15 PM, Resident #23 continued to have the hydrocortisone cream packet as well as a container of zinc oxide on his bedside table. Resident #23 said the nurse gave him the zinc oxide for his buttocks. During an observation and interview on 08/28/2025 at 2:11 PM, Resident #23 had the bottle of zinc oxide and a 30-milliliter cup of the white cream on his bedside table. He said the nurse brought the cream into him and told him to have the CNA to apply it when she came in to change him. During an observation and interview on 08/28/2025 at 2:15 PM, LVN S said she left the 30-mililiter medicine cup of white cream and the packet of hydrocortisone cream on accident, but no medication should be left at any resident's bedside. LVN S said the white cream was a prescribed medication Cream-SMBC (hydrocortisone, nystatin, zinc oxide) 1/1/1 that was ordered for a treatment for excoriation on Resident #23's buttocks. LVN S said the failure placed a risk for any person or resident getting the medications and ingesting or using incorrectly because you cannot identify what was in the medicine cup. During an interview on 08/28/2025 at 3:58 PM, the DON said she expected the charge nurses to administer and apply the medication when they go into the resident's room with the medications, and she expected the nurses to never leave medications in the residents' rooms. She said the facility staff had daily focus rounds, and the nurses completed rounds to prevent things like medications being left in the room from happening. The DON said the failure placed a risk for other residents getting the medications and ingesting it or using it while not knowing what it was. During an interview on 08/28/2025 at 4:34 PM, the Administrator said no medications should be left at the residents' bedside. She said the nurses were expected to stay in the room and administer if Resident #23 declined, and they should leave the room with the medication at hand. The Administrator said Resident #23 had not been care planned for medication at bedside. She said the failure placed a risk of Resident #23 and other residents entering the room have access to the medication and could ingest or take the medication. Record review of the facility's policy titled, Storage of Medications, dated 08/2024, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access.

Based on interview and record review, the facility failed to ensure the resident mail was delivered promptly and unopened for 1 of 10 residents (Resident #62) reviewed for communication. The facility failed to ensure that mail was delivered to Resident #62 unopened. This failure could place residents at risk of not receiving mail in a prompt and private manner and could result in a loss of personal property, frustration, and loss of dignity for the residents who reside at the facility.Findings included:Record review of Resident #62's face sheet, dated 08/28/25, reflected Resident #62 was a [AGE] year-old female readmitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #62's quarterly MDS assessment, dated 07/23/25, reflected Resident #62 usually made herself understood, and usually understood others. Resident #62's BIMS score was 13, which reflected her cognition was intact. Record review of Resident #62's comprehensive care plan, revised on 03/12/25, reflected Resident #62 had an ADL self-care performance deficit related to disease processes. The care plan did not reveal that the resident needed any assistance with opening packages. During a group meeting on 08/26/25 at 10:46 a.m., Resident #62 stated she ordered some items from amazon and the nurse opened her box without asking. Resident #62 stated the nurse told her I just wanted to make sure you didn't have any medications inside it. Resident #62 stated she told the nurse, I could have opened it in front of you, you didn't have to open my package. During an interview on 08/26/25 at 2:55 p.m., LVN A stated she was not aware residents were supposed to receive unopened mail. LVN A stated she was told by the receptionist she believed it was medicine because of the way the package sounded when it was shaken. LVN A stated when she opened the package it was makeup brushes. LVN A stated Resident #62 was upset when she delivered her package opened. LVN A stated that it would be against their rights if she did not get permission. During an interview on 08/26/25 at 2:58 p.m., Resident #62 stated, I was offended when she told me why the packaged was opened. Resident #62 stated she was aware she was not supposed to have medication delivered to the facility. During an interview on 08/27/25 at 8:52 a.m., the receptionist stated she was the only receptionist that delivered mail to residents. The receptionist stated she did not recall telling LVN A she thought Resident #62 packaged included medications. The receptionist stated whenever she delivers mail to residents the packages were unopened. The receptionist stated it was their right to receive unopened mail. During an interview on 08/28/25 at 1:50 p.m., the DON stated the receptionist takes the mail to the social worker to distribute the mail. The DON stated she was made aware this week that LVN A opened Resident #62 without her being present because she was thought it was medication. The DON stated if there was a policy and procedure regarding mail distribution the policy should be followed. The DON stated it was Resident #62 right to received mail unopened. During an interview on 08/28/25 at 3:39 p.m., the Administrator stated her expectation was for staff to deliver the mail to the resident unopened. The Administrator stated she was not aware LVN A opened the mail prior to delivering the resident. The Administrator stated if she had of known she would have given her three days of suspension and would have reported to HHSC. The Administrator stated she monitored by daily rounds by engaging with residents. The Administrator stated it was important residents received their mail unopened because it was their right. Record review of the facility's policy titled, Resident Rights, revised 12/2016 reflected. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: cc. access to a telephone, mail and email.

Based on observation, interview, and record review, the facility failed to provide assistive devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents. The facility failed to ensure CNA A utilized a mechanical lift and had assistance from another staff member during a bed to wheelchair transfer on 05/05/25 which resulted in Resident #1 having complaint of pain to the right ankle. An x-ray was conducted on 05/05/25 with the results of evidence of acute fracture of the right distal tibia (bone in the lower leg). The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 05/05/25 and ended on 05/07/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for falls resulting in injury, pain, and hospitalization. Findings included: Record review of a face sheet dated 05/19/25 indicated Resident #1 was a [AGE] year-old male admitted on [DATE]. His diagnoses included diagnoses included a wedge compression fracture of 4th lumbar (L4) vertebrae (one side of the 4th bone in the lower back collapsed) onset date 01/09/24. Record review of an MDS OBRA assessment dated [DATE] indicated Resident #1 had moderately impaired cognitive skills. He required partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort for chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Record review of an MDS OSA assessment dated [DATE] indicated Resident #1 had moderately impaired cognitive skills. He required extensive assistance when resident was involved in activity, staff provide weight-bearing support with two+ persons physical assist. Record review of a care plan initiated on 12/22/21 indicated Resident #1 required the use of mechanical lift with total assistance by 2 staff to move between surfaces every 2 hours and as necessary. Record review of the [NAME] (electronic care task utilized by care staff) printed 05/20/25 indicated Resident #1 had special instructions to use the mechanical lift with 2 staff for all transfers every shift for chronic L4-L5 fracture. Record review of Resident #1's progress notes indicated: *an entry dated 05/05/2025 at 06:30 a.m. indicated CNA A reported that upon transfer from bed to wheelchair Resident#1 complained of right leg pain. The nurse went to assess the resident's leg. The resident was asked where he hurt, and he said his right ankle had pain. There was no swelling at the ankle no bruising was noted at this time. Will notify the oncoming nurse. *an entry dated 05/05/2025 at 06:42 a.m. indicated while CNA A assisted Resident #1 with transfer from bed to wheelchair the resident's right ankle was twisted. The resident complained of pain in the ankle and was medicated with prn dose of Tylenol 325mg. The physician's office was made aware and an order for an x-ray was given. Record review of an x-ray report dated 05/05/25 indicated Resident #1 had evidence of an acute fracture of the right distal tibia (bone in the lower leg) and osteopenia (a condition of lower-than-normal bone mineral density that may lead to a condition in which bones become weak and brittle). Record review of the facility's investigation report dated 05/12/25 indicated on 05/06/25 during the morning meeting discussion on incidents it was noted that Resident #1's x-ray results showed an acute nondisplaced fracture of the right distal 3rd of the tibia. Resident #1 was transported via ambulance via stretcher to the local hospital related to a right ankle fracture. The Administrator's questions led to CNA A admitting to the DON that on 05/05/25 he did not use the Mechanical lift nor get assistance from another staff which Resident #1 required. During an interview on 05/20/25 at 10:30 a.m., the Administrator said CNA A was transferring Resident #1 without using the mechanical lift and a second staff on 05/05/25. She said Resident #1's right foot was turned and complained of pain afterwards. She said the physician was notified and an order was received to obtain an x-ray, but the resident refused because he wanted to go to dialysis first. She said when Resident #1 returned to the facility an x-ray was done. She said the result was received and the resident had a fracture of the lower leg. She said CNA A admitted he did not use the mechanical lift or have a second staff member with him to transfer Resident #1. She said he had been suspended and was terminated. She said all staff were trained upon hire and yearly on how to access the [NAME] in the kiosk (a small wall mounted computer used for providing resident information and staff to document care) to determine what care and how many staff were needed for care for each resident. During an observation and interview on 05/20/25 at 04:15 p.m., Resident #1 was in the bed. He was clean, neatly groomed, and had no offensive odors. He was wearing an orthopedic boot to his right lower leg. He said the male CNA who transferred him to the wheelchair stronged him - indicated by making a hugging gesture. He said he did not use a gait belt or a Mechanical lift. He said CNA A always stronged him and everyone else used a Mechanical lift. He said he wished it did not happen. He said he did not ask him not to use the Mechanical lift. He said everyone else transferred him with the Mechanical lift. The surveyor attempted to contact CNA A for an interview on 05/19/25 01:29 p.m. He did not respond. On 05/21/25, the surveyor confirmed the facility implemented appropriate measures to ensure the safety of residents after the incident on 05/05/25-05/07/25 involving Resident #1 by the following: Record review of CNA A's Disciplinary Action form dated 05/06/25 indicated he was suspended starting on 05/07/25 through 05/12/25. CNA A was then terminated. Record review of Proficiency Trainings provided to staff upon hire and annually which included training on the Point of Care to access the [NAME], and Mechanical Lift Transfers for CNA S hired on 05/13/25 and LVN X hired on 05/15/25. Record review of In-Services on 05/06/25 after the incident on 05/05/25 included: Pain to be Reported was received by AD, MR, Transportation, RA, DOR, LVN D, LVN E, CNA F, CNA G, LVN H, LVN J, LVN K, MA M, CNA O, CNA P, CNA Q, CNA R, CNA S, LVN T, CNA U, and CNA V. Falls was received by AD, MR, Transportation, RA, DOR, LVN D, LVN E, CNA F, CNA G, LVN H, LVN J, LVN K, MA M, CNA O, CNA P, CNA Q, CNA R, CNA S, LVN T, CNA U, and CNA V. ANE was received by AD, MR, Transportation, RA, DOR, LVN D, LVN E, CNA F, CNA G, LVN H, LVN J, LVN K, MA M, CNA O, CNA P, CNA Q, CNA R, CNA S, LVN T, CNA U, and CNA V. Resident Rights was received by AD, MR, Transportation, RA, DOR, LVN D, LVN E, CNA F, CNA G, LVN H, LVN J, LVN K, MA M, CNA O, CNA P, CNA Q, CNA R, CNA S, LVN T, CNA U, and CNA V. ACCURATELY CODING ADLs WHEN DOCUMENTING ADL's, RN's, LVN's and RCP's can check several areas of resident chart when needing information refer to resident's: care profile/special instructions, [NAME], care plan, and POC instructions to ensure documentation is accurate was received by RA, LVN D, LVN E, CNA F, CNA G, LVN H, LVN J, LVN K, MA M, CNA O, CNA P, CNA Q, CNA R, CNA S, LVN T, CNA U, and CNA V. Observations of staff with mechanical lift transfers of Resident #1 on 05/19/25 at 02:34 p.m. and on 05/20/25 at 08:38 a.m. and Resident #3 on 05/21/25 at 08:38 a.m. indicated no observed concerns with transfer assistance. During an interview on 05/19/25 at 08:00 a.m. LVN J said she worked 6a-2p and 2p-10p shifts. She said CNAs were to check the kiosk for the [NAME] which provided information on how much assistance and how many staff were needed for care on residents such as eating, bathing, and transfers. She said she knew how to look up the information if a CNA had questions. She said Resident #1 had always required a Mechanical lift and 2 staff for transfers due to a compression fracture of a vertebrae in his spine. She said recently he had started working with restorative only for sitting to standing. She said the CNAs were not have him stand for transfers. During an interview on 05/19/25 at 01:15 p.m. CNA F said the kiosk had a [NAME] which would let him know what assistance and how many staff were needed for resident care. During in interview on 05/19/25 at 01:20 p.m. CNA G said she looked up the [NAME] on the kiosk to know what assistance and how many staff were needed for resident care. During an interview on 05/20/25 at 08:30 a.m. CNA O said she worked 6a-6p shift. She said she looked up the resident [NAME] on the kiosk so she would know if a resident needed assistance, what kind of assistance (staff or mechanical lift), and how many staff were needed. She said she worked with Resident #1 and he had always had to have a Mechanical lift and 2 staff for transfers. During an interview on 05/20/25 at 09:13 a.m., MA M said she worked the 6a-6p shift. She said to find the resident's information to know what assistance they needed staff would look on the [NAME] in the kiosk. She said as far as she knew all staff were trained on how to look up the [NAME] on the kiosk. During an interview on 05/20/25 at 01:32 p.m. CNA P and CNA Q said they worked the 6a-6p shift. They said they looked up what kind of assistance a resident needed on the [NAME] located in the kiosk. They said they would assist when Resident #1 needed to be transferred because he used a Mechanical lift and 2 staff with all transfers. During an interview on 05/21/25 at 12:12 p.m. CNA R said he worked 6a-6p shift. He said he received training regarding resident abuse, neglect, rights and resident [NAME] care levels. He verbalized understanding of the trainings and was able to give examples of resident [NAME] care levels and he would ask for assistance if required. During an interview on 05/21/25 at 12:14 p.m. CNA S said she worked 6a-6p shift. She said she received training regarding resident abuse, neglect, rights and resident [NAME] care levels. She verbalized understanding of the trainings and was able to give examples of resident [NAME] care levels and she would ask for assistance if required. During an interview on 05/21/25 at 12:16 p.m. LVN T said she worked whatever shift she was needed. She said she received training regarding resident abuse, neglect, rights and even received training on resident [NAME] care levels. She verbalized understanding of the trainings and was able to give examples of resident [NAME] care levels and she would assist if required. During an interview on 05/21/25 at 12:18 p.m. LVN D said she worked the 6a-2p shift. She said she received training regarding resident abuse, neglect, rights and also resident [NAME] care levels. She verbalized understanding of the trainings and was able to give examples of resident [NAME] care levels and she would assist if required. During an interview on 05/21/25 at 12:19 p.m. LVN E said he worked the 6a-2p and 2p-10p shifts. He said he received training regarding resident abuse, neglect, rights and also resident [NAME] care levels. He verbalized understanding of the trainings and was able to give examples of resident [NAME] care levels and he would assist if required. During an interview on 05/21/25 at 12:20 p.m. CNA U said she received training regarding resident abuse, neglect, rights and resident [NAME] care levels. She verbalized understanding of the trainings and was able to give examples of resident [NAME] care levels and she would ask for assistance if required. During an interview on 05/21/25 at 12:26 p.m. LVN K said she worked the 6a-6p shift. She said she received training regarding resident abuse, neglect, rights and also resident [NAME] care levels. She verbalized understanding of the trainings and was able to give examples of resident [NAME] care levels. She said she would assist if required. She said Resident #1 had always been a Mechanical lift and 2 staff for transfers because he had a compression fracture of a vertebrae in his back. During an interview on 05/21/25 at 12:28 p.m. CNA V said worked the 6a-6p shift. She said she received training regarding resident abuse, neglect, rights and resident [NAME] care levels. She verbalized understanding of the trainings and was able to give examples of resident [NAME] care levels and she would ask for assistance if required. During an interview on 05/21/25 at 12:30 p.m. LVN H said she received training regarding resident abuse, neglect, rights and also on resident [NAME] care levels. She verbalized understanding of the trainings and was able to give examples of resident [NAME] care levels. She said she would assist if required. The noncompliance was identified as PNC. The Immediate Jeopardy began on 05/05/25 and ended on 05/07/25. The facility had corrected the noncompliance before the investigation began.

Based on observation, interview, and record review, the facility failed ensure the environment was free of hazards to prevent accidents for 1 of 12 residents (Resident #1) reviewed for hazards and accidents. The facility failed to ensure Resident #1's wheelchair was secured properly in the facility's transport vehicle. Resulting in Resident #1 tipping over sideways, hitting his head, and sustaining a hematoma. This failure could place residents at risk for serious injury, decreased level of functioning, and diminished quality of life. Findings included: Record review of a face sheet, dated 10/07/22, indicated Resident #1 was [AGE] years old, admitted on [DATE], and diagnoses included unspecified sequelae of cerebral infarction (a pathological condition resulting from a disease, injury, therapy, or other trauma), lack of coordination (inability to coordinate bodily movement), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term [CONDITION(S)] or a kidney transplant to maintain life), type II diabetes (an impairment in the way the body regulates and uses sugar as a fuel), major depressive disorder (a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), generalized anxiety disorder (a persistent feeling of anxiety or dread that interferes with how you live your life), cognitive communication deficit (difficulty with thinking and how someone uses language), and dysarthria (slurred speech). Record review of an MDS assessment, dated 08/19/22, indicated Resident #1 had a BIMS score of 14 (cognitively intact), required supervision to walk in room, required limited assistance for transfers, utilized a wheelchair for mobility, was not steady but could stabilize himself moving from a seated position, walking, turning around, moving on and off the toilet, and surface to surface transfer. He utilized a wheelchair for mobility. He was occasionally incontinent of bladder and bowel. Record review of physician order dated 10/03/22 indicated to monitor hematoma/scab on the back of Resident #1's head every shift. Record review of physician order dated 04/20/22 indicated Resident #1 received [MEDICATION(S)] (an antiplatelet blood-thinning medicine) that may help prevent future heart attacks, strokes, and other clot-related diseases in patients who have already had a heart attack, stroke, or have certain cardiovascular conditions). Record review of a care plan, dated 10/03/22, indicated Resident #1 sustained a hematoma and scab to the back of his head related to a fall while riding in the facility's van. An intervention included monitor, document, and report any abnormalities (failure to heal, infection, maceration) to MD. Record review of progress note, dated 10/03/22 and completed by LVN A, indicated ADON B received a call from CNA C. CNA C reported she was driving back to the facility, turned a corner, and Resident #1 fell out of the wheelchair. CNA C stated he was strapped it looked like the straps did not lock good to the floor and when I turned he fell towards his left, he hit his head. He has a bruise to the back of his head and is complaining of pain, we are at [hospital] ER, the administrator know, she told me to bring him. LVN A asked what pain level and documented 8/10. Record review of an incident report, dated 10/093/22 and completed by LVN A, indicated Resident #1 fell from his wheelchair during transport and hit his head. The physician was notified. Resident #1 was taken to the ER. Record review of progress note dated 10/03/22 and completed by LVN A, indicated Resident #1 returned to the facility via stretcher, he was transferred to bed. Resident #1 denied pain, did not have a headache, and denied dizziness. He sustained a hematoma to the back of his head (6 X 5 X <0.1) with a scab to the center (1.3 x 1.3 x < 0.1). Review of CNA C's training record indicated she was added to the facility's Authorized Driver's list on 04/29/22. CNA C's training record included Securing Residents in Van - Competency Demonstration dated 04/29/22, checked off, and signed by CNA C indicated Strap passenger's wheelchair front first from the lower bottom bar on top of the wheel. Straps should attach to a solid, structural frame member of wheelchair. Apply the brake on the wheelchair. Strap the rear of the wheelchair to the floor of the vehicle. Straps should not interfere with the wheelchair foot rests and any fittings should be firmly engaged and locked in the appropriate slot of the track. Prior to transport, make a final check of all secured passengers to ensure that all straps are properly attached. If there are any wheelchairs, be sure that they are secured and there is no possible movement from the front to rear or from side to side. CNA C's training record indicated she had not completed the required training videos (Safe Driving Video, Sure Lok Video, Braun Video, and [NAME] Wheelchair Lift Video), prior to being allowed to drive the facility transport vehicle. During an interview on 10/06/22 at 2:10 p.m., the Administrator said the facility's transport driver (CNA C) indicated the right front strap would not stay in place. She said CNA C should not have proceeded with transport when the strap used to secure the wheelchair was not working. She said the wheelchair would not tip over if it was properly secured. The Administrator said CNA C should have called her, the DON or the ADON and reported the strap was not working before transporting Resident #1. She said Resident #1 was transported to the ER and was evaluated and returned to the facility the same day. She said Resident #1 sustained a hematoma to the back of his head. She said residents could sustain serious injury, or impairment if they and their wheelchairs were not secured properly prior to transport. She said she was not aware CNA C had not watched the required training videos. During an interview on 10/06/22 at 3:34 p.m., CNA C said she picked Resident #1 up from [CONDITION(S)]. She said the strap used to secure the right front of Resident #1's wheelchair was giving her issues. She said she put the other three straps on successfully. She said the wheelchair brakes were locked and the seat belt was secured. She said she pulled out of the [CONDITION(S)] parking lot and made a right turn at the light. She said she looked in the rearview mirror and saw Resident #1 was tipped over. She said she put on the hazard lights and pulled into a gas station and stopped. CNA C said Resident #1 indicated he hit his head. She said she called ADON B and reported the incident. She said ADON B indicated she would call the Administrator. ADON B said she could pick him up and take him to the ER after she walked her through an assessment. She said she left Resident #1 at the ER after his family member arrived. She said she moved Resident #1's wheelchair over in the transport van and utilized 4 working straps. CNA C said when asked why she did not move Resident #4's wheelchair over and utilize four working straps before leaving the [CONDITION(S)] parking lot, she said she just wasn't thinking. She said she was shown how to hook up the straps correctly when she started her position as a transport driver in April of 2022. She said she was trained but checked herself off on the competencies. She said she had to return demonstrate to the Administrator, on 10/04/22, proper securing of a resident in a wheelchair in the facility transport vehicle, prior transporting residents after the incident on 10/03/22. CNA C said she had not watched the required training videos (Safe Driving Video, Sure Lok Video, Braun Video, and [NAME] Wheelchair Lift Video), prior to being allowed to drive the facility transport vehicle on 04/29/22 or since the incident on 10/03/22. She said she was not aware of the training videos. During an interview on 10/06/22 at 3:47 p.m., MS D said he tested all the straps, and the straps were in working order on 10/04/2022. He said the straps on the facility's transport van locked in place and were in working condition. He said he could not recreate the right front strap (that was supposed to be on Resident #1's wheelchair) not working. He said he checked the straps in the van once a month to ensure they were in working order. He said he had no other reports of the straps not working correctly. During an observation and interview on 10/07/22 at 8:32 a.m., Resident #1 said he thought the straps were hooked to his wheelchair. He said when CNA C made a right turn, he tipped over and hit his head. He said he was okay. He said he had to go to [CONDITION(S)] 3 times a week and had not tipped over before 10/03/22. He said he was not afraid to travel in the facility's transport. CNA A proceeded to hook up Resident #1's wheelchair in the facility's transport van. She indicated the right front strap appeared to be in working condition and locked the strap in place on left front of Resident #1's wheelchair. CNA C locked the remaining three straps on to Resident #1's wheelchair and checked all straps to ensure the straps were secured in place. All straps were in working condition. Record Review of the facility's undated Driver and Vehicle Safety Manual indicated The objective of this policy is to implement safe driving practice so that the following goals are met: .No employee or resident injuries in or around vehicle. Residents are properly secured at all times.

Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 20 residents (Resident #20) reviewed for pain management. The facility failed to identify Resident #20 had pain to her left hip. The facility failed to assess Resident #20 after her RP reported complaints of hip pain to a CNA (CNA E). CNA E failed to report Resident #20's RP concern of hip pain to nurse for resident to be assessed. Resident #20 was assessed two days later after RP reported hip pain again; NP ordered an xray and was diagnosed with a hip fracture. This failure could place residents at risk of not receiving timely care, health complications and decline in functioning. Findings included: Record review of Resident #20's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #20's significant change MDS dated [DATE] revealed a BIMS score of 9 which indicated moderate impaired cognition. The MDS revealed Resident #20 required extensive assistance with one person for transfer, dressing, toilet use, and personal hygiene. Further review of the MDS revealed she had received scheduled and PRN pain medication in the last 5 days. Resident #20 was noted to have 2 falls with no injury since last assessment. Record review of Resident #20's care plan revised on 3/24/22 revealed she had a potential for pain and was at risk for injury from a decrease is ADL's. The interventions included: Assess characteristics of pain: Location, Severity, on a scale of 1-10, type and frequency. Discuss with resident factors that precipitate pain and what may reduce it. Administer pain medications as ordered. Discuss with resident the need to request pain medications before pain becomes severe. Discuss with physician that for maximum pain relief pain medication are best given around the clock, with PRNs for breakthrough pain. Monitor for potential side effects of pain medication. Record review of Resident #20's care plan revised on 3/25/22 revealed Resident #20 have had an actual fall on 2/22/2020, 3/25/20, 3/28/20, 4/14/20, 6/1/2020, 6/8/20, 6/9/2020, 2/1/22, 2/7/22, 2/26/22, 3/2/22, 3/10/22, and 3/25/22. Her interventions included: 2/1/22- therapy screen, 2/26/22-landing strips at bedside, 2/7/22-bed in lowest position, 3/10/22 -STAT CBC, 3/2/22-nonskid socks, CBC, 3/25/22-low bed, 3/3/22-orthostatic BP checks x 3 days, 4/14/20-Stat labs, 6/8/20- resident education to lock wheelchair, 6/9/2020 Orthostatic BP qshift x3 days, fall mat in place, 3/25/20 educated to use call light for assistance due to unsteady gait, landing strips to bedside, Monitor/document /report PRN x 72h to MD for signs and symptoms: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Record review of Resident #20's care plan initiated on 3/22/22 revealed she had an alteration in musculoskeletal status related to fracture of the (acute left subcapital hip fracture) ( These fractures occur in the neck of the thighbone). Her interventions included: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Educate the resident/family/caregivers) on joint conservation techniques. Follow MD orders for weight bearing status. See MD orders and/or PT treatment plan. Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness. Monitor for any side effects to NSAIDS such as GI bleeding or renal impairment. Monitor for fatigue. Plan activities during optimal times when pain and stiffness is abated. Monitor/document for risk of falls. Educate resident/family /caregivers on safety measures that need to be taken in order to reduce risk of falls. (If resident has a care plan for falls, refer to this). Monitor/document/report PRN signs or symptoms or complications related to arthritis: Joint pain; Joint stiffness, usually worse on wakening; Swelling; Decline in mobility; Decline in self-care ability; Contracture formation/joint shape changes; Crepitus (creaking or clicking with joint movement); pain after exercise or weight bearing. Record review of care plan dated 12/8/2021 revealed she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her interventions included: Anticipate needs and assist with care as needed. Assist resident carefully when providing care. Diet as ordered. Encourage to exercise and attend activities as tolerated. Give medications per MD orders- monitor labs/x-rays and report abnormal results to MD. HAS ORDER FOR VITAMIN D and Calcium, provide for pressure relieving and positioning devices as required. Record review of Resident #20's progress notes dated 3/10/22 at 4:45PM written by LVN R revealed, nurse was called to the room by the aide stating the patient is sitting on the floor. Nurse entered room and noted patient sitting on the floor at the side of her bed. Patient states she was trying to get her baby from under the bed. Patient has no complaints of pain at this time. Patient exhibits no signs or symptoms of distress at this time. Nurse has initiated neuro checks. Nurse contacted DON and will implement staff education and labs have been ordered. Nurse also received order from NP to get a psych consult. Nurse called RP, but there was no answer. Nurse will attempt to contact RP at a later time. Will continue to monitor. Record review of Resident #20's pain tool dated 3/10/22 at 8:22PM completed by LVN R revealed she had no complaints of pain. Record review of Resident #20's progress notes dated 3/10/22 - 3/20/22 revealed no documentation of resident having pain. Record review of Resident #20's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #20's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #20 March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #20's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #20's progress note dated 3/21/22 at 1:48PM, LVN I noted Acetaminophen ER tablet 650mg as needed for pain was administered for complaints of hip pain. Record review of Resident #20's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #20's progress notes dated 3/21/22 at 5:32PM revealed, LVN I completed an SBAR with the situation being uncontrolled pain. Nursing assessment revealed in part, .Resident up to wheelchair and complained of pain to left hip to RP this nurse assessed left hip and complained of pain when ROM done to left hip no swelling noticed or warm to touch, administered prn Tylenol 650mg 1tablet, and called np . Further review of the note revealed the NP order a left hip x-ray. Record review of Resident #20's progress notes dated 3/21/22 at 5:53PM revealed LVN I noted PRN Acetaminophen ER tablet 650mg 1 tablet by mouth every 4 hours as needed for pain was administered for complaints of left hip pain. Record review of Resident #20's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #20's Left hip x-ray revealed an examination date of 3/21/22 at 4:13PM and a report date of 3/21/22 at 5:15PM. The left hip x-ray results revealed in part, .Acute left subcapital hip fracture . Record review of Resident #20's progress notes dated 3/21/22 at 6:18PM revealed LVN I charted, Notified DON and Administrator about fracture will continue to monitor. Record review of Resident #20's progress notes dated 3/21/22 at 6:29PM revealed LVN I charted, This nurse received x-ray results notified np about results showed Acute left subcapital hip fracture. Np new order to transfer to ER, this nurse called RP and she stated I don't want her to have surgery she won't make it threw I don't want her to have anything done just keep her comfortable with the pain this nurse recommended consult with bone and joint specialist and RP still refused to have consult set up stated let me call my family and will call back, this nurse notified np about RP decision will continue to monitor administered prn Tylenol 650mg one tab for pain will continue to monitor resident is comfortable in bed eating supper. Record review of Resident #20's progress notes dated 3/21/22 at 6:36PM revealed LVN I charted. Resident RP called this nurse and stated, I spoke with family, and we are doing hospice can you get a consult with hospice, and we want her to be comfortable no surgeries or anything done this nurse called np and received order for hospice. Record review of Resident #20's progress notes dated 3/21/22 at 6:50PM revealed LVN I charted, Received new order to discontinue Tylenol 650mg 1 tab, Tylenol 500mg po q9am and 9pm for 2 weeks for pain to left hip RP is notified of new order will continue to monitor and faxed records to hospice. Record review of Resident #20's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility investigation into Resident #20's injury of unknown origin signed on 3/24/22 by the Administrator revealed on 3/21/22 at 5:32PM Resident #20 was up in her wheelchair and complained of left hip pain to her RP. LVN I assessed Resident #20's left hip and noted she complained of pain when range of motion was done to the left hip. LVN I was noted to administer Resident #20 PRN Tylenol and called the NP, DON, Administrator and RP. Residents and staff were interviewed by the ADON, and Resident #20 was noted to have a recent fall on 3/10/22 in which the head-to-toe assessment after her fall revealed she had no complaints of pain or discomfort. Staff were noted to be in-service on injury of unknown origin and reporting. The facility investigation findings were inconclusive. The action noted to be taken was an x-ray ordered by the NP which showed a left subcapital hip fracture. The NP was informed of the x-ray results, and she ordered to transfer Resident #20 to the hospital, but the RP insisted she did not want the resident transferred to the hospital due to her age and requested the staff make her comfortable with the pain. The NP ordered Resident #20 to receive routine [MEDICATION(S)] for the pain. Record review of CNA J written statement dated 3/23/22 revealed in part, . I have no idea how Resident #20 received a fracture. I worked on Saturday 3/19/22 and she never complained of pain . Interview and observation on 3/29/22 at 9:30AM, Resident #20 was lying in bed with her breakfast in front of her on bedside table. Resident #20 said she was doing well but said she was not able to move around much because she would hurt from her hip fracture. Resident #20 said she had a lot of falls in the facility and said she presumed that was how she fractured her hip. Resident #20 said she did not feel the pain in her hip right after she had a fall. Resident #20 could not remember when her last fall was or when she last fell before feeling the pain in her hip. Resident #20 said she told her RP about her hip pain and the RP reported it to the staff. Resident #20 said the facility did an x-ray on her and found out she had a fracture after she told her RP about the pain. Resident #20 could not recall how much time passed from the time she reported having the hip pain and when she got the x-ray. Resident #20 said she got medication for pain and said the nurses would bring more medication for pain if she needed it. Interview on 3/30/22 at 10:35AM, LVN I said around lunch time on 3/21/22 Resident #20's RP told her Resident #20 had complained about her hip hurting. LVN I said she went to assess Resident #20 and noted she did complain of pain in her left hip when she went to move her leg. LVN I said she gave Resident #20 medication for the pain and notified the physician and who ordered an x-ray. LVN I denied observing Resident #20 in pain prior to the RP reporting it to her that day. LVN I said Resident #20 received a shower that morning and the CNA did not report any issues with pain nor had any other staff from previous shifts reported pain issues for Resident #20. LVN I said Resident #20's RP did tell her on 3/21/22 she had visited Resident #20 on Saturday (3/19/22) and noticed the resident was complaining of pain to the left hip. Interview on 3/30/22 at 10:51AM, CNA K said she worked with Resident #20 the morning of 3/21/22 and there were no complaints of pain. CNA K said she did Resident #20's ADL's and showered her that morning and she was okay. CNA K said Resident #20's RP was visiting on 3/21/22 (Monday) and told the nurse (LVN I) Resident #20 was complaining of hip pain and reported Resident #20 had hip pain over the weekend when she visited her. CNA K said LVN I assessed Resident #20 after the RP reported the pain to her and found Resident #20 did have some pain to her left hip. CNA K said the facility got an x-ray done and found she had a hip fracture. CNA K denied having any previous complaints of pain from Resident #20. Interview on 3/30/22 at 12:42PM, Resident #20's RP said she visited with Resident #20 on Saturday (3/19/22) and said the first thing she noticed was while Resident #20 was in her wheelchair in the dining hall she was guarding her leg and told her not to move when she went to help her adjust in her wheelchair. She said Resident #20 told her she would move her own leg because she was having some pain. The RP said later the CNA went to transfer Resident #20 to bed and she noticed the resident was grimacing during the transfer . The RP said she asked Resident #20 if she was having pain and Resident #20 told her she was having some pain in her left hip. The RP said she reported Resident #20 was having some pain in her left hip to Resident #20's CNA that day and she expressed they needed to do an x-ray to see what was going on. The RP said the CNA told her she would have the nurse look at Resident #20. The RP said she did not know the name of the aide and said she was someone she had not seen before. The RP said she visited with Resident #20 again on 3/21/22 and noticed Resident #20 was still having pain in her hip. She said when she spoke to LVN I on 3/21/22 and she did not not know about Resident #20's pain and had not done an x-ray . The RP said the nurse LVN I assessed Resident #20 and observed she had hip pain, contacted the NP, and ordered the x-ray in which they found the left hip fracture. The RP said she suspected Resident #20 might have had a fracture on 3/19/22 which is why she wanted them to do an x-ray to check then. She said she was worried about them continuing to transfer and move Resident #20 if she did have a fracture because it might have made the fracture worse. Interview on 3/30/22 at 4:31PM, LVN L said she was Resident #20's nurse on 3/19/22 during the day shift. LVN L said she had no observation of Resident #20 being in pain and said no one reported to her Resident #20's RP had concerns of her being in pain. Interview on 3/30/22 at 6:06PM, CNA J said she was an agency CNA and said she had worked with Resident #20 on 3/19/22. CNA J said Resident #20's RP was at the facility visiting on 3/19/22 and the RP did tell her she was worried about Resident #20 having some hip pain. CNA J said the RP said she was going to tell the nurse about the pain so they could get an x-ray. CNA J said she did not observe the resident in pain and Resident #20 did not tell her personally about the pain she was having. CNA J said she did not tell the nurse about the pain Resident #20's RP reported because the RP said she was going to tell the nurse and because she did not observe Resident #20 in pain . CNA J said if she would have observed Resident #20 in pain she would of informed the nurse. Interview on 3/30/22 at 6:25PM, the DON said it did not come out in their investigation that Resident #20's RP had reported concerns of Resident #20 being in pain on 3/19/22. The DON said they had a statement from CNA J where she noted Resident #20 had no pain on 3/19/22 and through their investigation there were no signs of Resident #20 having hip pain prior to 3/21/22. The DON said CNA J never reported during the investigation the conversation, she had with Resident #20's RP. The DON said the CNA should report any concerns of pain or change either the resident or RP reports to the nurse even if the RP said they were going to tell the nurse themselves. The DON said CNA J was an agency nurse and said they were trained through their agency and should know to report changes immediately to the nurse so the nurse could assess the resident and notify physician of change . The DON said she ensures the staff have completed the required training through their agency before they start but she was unable to present specific information covered in the training to surveyor. Record review of the facility Change in a Resident's Condition or Status (Revised May 2017) revealed in part, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the residents medical/mental condition/ or status . 1. The nurse will notify the residents Attending Physician or physician on call where there has been a(an) . d. significant change in the resident's physical/emotional/mental condition Record review of the facility undated Pain Management Policy revealed in part, .The onset of acute pain may indicate a new injury or a potentially life-threatening condition or illness. It is important, therefore, that a resident's reports of pain, or nonverbal signs suggesting pain, be evaluated . 4. A pain evaluation will be completed upon admission, readmission, and any new episode of pain episode of pain or exacerbation of pain

Based on interview and record review, the facility did not ensure the physician or resident representative was consulted regarding a significant change of physical status for 1 of 6 residents reviewed for change in condition. (Residents #5) The facility did not notify Resident #5's family or immediately consult with the resident's physician when the staff found wounds on the toes of the resident's left foot. The resident was admitted to the hospital 25 days later with dry gangrene (caused when blood flow is impaired causing the tissue to dry up, be brown to purplish-blue to black in color and often falls off) to her second and third left toes. This failure could place residents at increased risk for complications due to delayed physician intervention. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 9/29/20. While the IJ was removed on 10/1/20, the facility remained out of compliance at actual harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: Physician orders [REDACTED].#5 admitted [DATE], was [AGE] years old, and had [DIAGNOSES REDACTED]. A care plan dated 7/11/19 for Resident #5 indicated the resident was at risk for pressures ulcers due to immobility. A care plan intervention indicated a skin assessment was to be completed upon admission and at least weekly thereafter. A care plan updated 9/1/20 for Resident #5 indicated the resident had wounds on her left toes. The care plan interventions indicated the facility was to monitor the areas for increased breakdown or signs and symptoms of infection, and report any changes to the physician. The care plan indicated the facility was to assess the resident's skin weekly and record findings in the clinical record. An MDS assessment dated [DATE] indicated Resident #5 had severe cognitive impairment and required extensive to total assistance with all activities of daily living. There were no skin issues identified on the assessment but the resident was identified as being at risk for developing pressure ulcers. A skin assessment dated [DATE] indicated Resident #5 had no skin issues. A skin assessment dated [DATE] completed by LVN A indicated Resident #5 had a stage II pressure injury on the 2nd toe of her left foot. The assessment did not include a description or measurements of the pressure injury. There was no documentation of physician notification. The August 2020 MAR indicated [REDACTED]. During an interview on 9/22/20 at 10:18 a.m., the DON said LVN A got an order for [REDACTED]. A physician order [REDACTED].#5 was to receive skin prep to her left toe wounds daily. A nursing progress note dated 8/21/20 at 9:42 p.m. completed by LVN A indicated Resident #5 complained of a loss of sensation to her feet. LVN A contacted the NP for the medical director and received an order to get an appointment with a physician at a local bone and joint clinic. The note indicated LVN A called and left a message at the clinic and would follow up on Monday. During an interview on 9/22/20 at 10:51 a.m., LVN A said she did not recall anything about Resident #5's toes. She did not recall completing the assessment on Resident #5's toes on 8/20/20 or the resident complaining of a loss of sensation to her toes on 8/21/21. She did not remember if she called the physician or responsible party regarding the resident's toes and did not recall getting an order for [REDACTED].>A hospital history and physical dated 8/27/20 (while evacuated due to hurricane) indicated Resident #5 had issues that appeared to be a blister with rupture and desquamation (peeling) of the epidermis (skin) on the 3rd and 4th toes on the left foot. The history and physical indicated the resident's feet did not have swelling. During an interview on 9/21/20 at 1:08 p.m., Resident #5's daughter said the facility did not make the family aware of any concerns about the resident's toes on her left foot. She said while the facility was evacuated due to the hurricane, Resident #5 had to go to the hospital. She said her sister was able to see Resident #5 at the hospital on [DATE] and the resident's toes were a reddish purple color, but there was no open wound. She said the family was never told the resident's toes worsened. A skin assessment dated [DATE], completed by LVN C indicated Resident #5 had a wound to her left toes. The assessment did not contain the number or wounds, exact location, description or measurements of the wounds. The assessment did not indicate the physician or responsible was notified of the wound. During an interview on 9/21/20 at 1:08 p.m., Resident #5's daughter said her sister was watching the camera in her mother's room on 9/10/20 when staff closed the curtain to transfer the resident to bed. The sister heard Resident #5 tell staff to watch her foot. She then heard the resident scream. Resident #5's daughter said she called the facility and spoke with LVN B. She said LVN B went to her mother's room and touched the resident's toes and said her mother did not yell out. Resident #5's daughter said she talked to LVN B on 9/11/20 (Friday) about calling the physician. LVN B told her Resident #5's physician was bad about not returning calls on the weekend, but she would pass it on to LVN C to call Monday. She said she did not get a call from LVN C on Monday (9/14/20) so she called LVN C on Tuesday (9/15/20). LVN C told her she had not received any messages from LVN B and there was nothing documented in the chart. The daughter said LVN C called the physician and Resident #5 was sent to the hospital. The daughter said the physician at the hospital told her Resident #5's toes were dead and there was no circulation to her left foot. She said the family was told by the cardiologist and the foot doctor at the hospital Resident #5 was not a candidate for surgery. During an interview on 9/18/20 at 12:05 p.m., LVN B said the first time she saw Resident #5's foot was when the daughter called and asked her to go look at the resident's toes on 9/11/20. She said the resident's toes were purple in color. She said she did not call the physician about the resident's toes. A skin assessment dated [DATE] (11 days after the last documented assessment) completed by LVN F indicated Resident #5 had a wound to her left toes. The assessment did not contain the number of wounds, exact location, a description, or measurements of the wound. The assessment did not indicate the physician was notified of the wound. During an interview on 9/17/20 at 4:40 p.m., CNA G said she worked the weekend before Resident #5 went to the hospital (9/12/20-9/13/20). She said the two middle toes on the resident's left foot looked like the skin was coming off. She said the toes were dark purple. She said before the evacuation it just looked like a scrape. She said she reported the condition of the resident's toes to a nurse but could not remember who she reported to. Nursing progress notes dated 8/20/20 through 9/15/20 for Resident #5 did not include any evidence of physician notification regarding Resident #5's toes until the resident was sent to the hospital on [DATE]. Physician/Nurse Practitioner progress notes dated 9/10/20, indicated no mention of any skin issues. During an interview on 9/28/20 at 3:42 p.m., the nurse practitioner for Resident #5's physician said she was not the one the facility would call for orders or notifications. She said she spoke with the physician's nurse who fields his calls. She said the nurse told her she had not received any calls about Resident #5's toes until 9/15/20 when she was sent to the hospital. During an interview on 9/22/20 at 10:18 a.m., the DON said she was not aware of the wound on Resident #5's toes until 9/15/20. The DON said they had a wound care physician who made rounds weekly but Resident #5 was not referred to the wound care physician because she was not aware of the resident's wounds. She said LVN B should have called her and the medical director if a physician was not returning calls. She said LVN C told her Resident #5's toes did not look black the day before she went to the hospital. An emergency room nursing note dated 9/15/20 indicated left toe infection, extremity pain/Swelling nontraumatic. The physician's emergency room visit notesrecord dated 9/15/20 indicated Resident #5 had moderate to severe [MEDICAL CONDITION]. The physical exam indicated Resident #5 had dry gangrene (caused when blood flow is impaired causing the tissue to dry up, be brown to purplish-blue to black in color and often falls off) of the second and third toes with [DIAGNOSES REDACTED] (redness), mild swelling, and tenderness. A Wound Care Consultation note dated 9/17/20 indicated Resident #5 was on [MEDICATION NAME] 875 mg every 12 hours and recommended Hyperbaric oxygen therapy (used to treat wounds that will not heal) for her foot ischemia (inadequate blood supply). The facility's undated Skin Management System indicated 10. Keep open lines of communication with physicians, families, and residents regarding status of wounds. The administrator and DON were notified on 9/29/20 at 4:18 p.m. an IJ situation was identified due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 10/1/20 at 5:21 p.m. and included: Plan of IJ Removal for (Facility) 9/29/2020 Quality of Care and Notification Plan of Action Head-to-toe skin assessments were completed on 9/16/2020 on all residents (2 refusals but completed on 9/25/2020 & 9/23/2020) by Nursing Management. Head-to-toe skin assessments were completed the week of 9/21/2020 on all residents. Head-to-toe skin assessments were completed 9/30/2020 on all residents. Licensed Nurses were provided in-service education on 9/16/2020 and 9/30/2020 by DON/designee which includes: 1. Proper skin assessments on admission, weekly, and with a change of condition. 2. Identifying a change in condition of the wound and reporting it to attending physician and responsible party. 3. Daily wound monitoring, weekly assessment per schedule, and document the assessment on PCC. 4. Receiving orders on wounds from attending physician and ensure orders were carried out timely. 5. All assessments must include measurement and description of the wound. Nursing Administration initiated in-service education with Charge Nurses on 9/29/2020 about documenting any outside referrals in nurses notes and writing physician order. After referral is documented the Nursing Administration will pull the 24-hour report to review all new order in clinical meeting and follow-up accordingly. Regional Director of Clinical Operations performed in-service education on 9/30/2020 with DON and ADON on monitoring skin assessments, wound assessments, MD/RP notifications, and wound documentation. Nursing Management will assume performing responsibility of treatment nurse's role by completing skin assessments, wound assessment, and wound care until treatment nurse returns from leave of absence. Validation/Monitoring Tools The skills validation for skin/wound assessments to be conducted by the DON with all the Nursing Management to ensure competency by 9/30/2020. 24-hour report will be reviewed in clinical meeting by DON/Designee to identify any new skin concerns and to ensure assessment was completed, order obtained for wound, and MD/RP notification. New order listing report will be reviewed in clinical meeting by DON/Designee to ensure referral follow-up. UDA tool will be utilized by DON/Designee to audit skin assessments for completion. QAPI The Administrator held an Ad hoc QAPI meeting on 9/16/2020 to develop a plan of action related to skin integrity, documentation, and family/MD notification. The Administrator will review the action plan developed related to skin integrity, documentation, and family/MD notification monthly during the QAPI meeting. On 10/1/20 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: An in-service dated 9/30/20 indicated all nurse managers were trained on skin assessments, wound assessments/documentation, responsible party and physician notification, and ensuring a treatment is in place for all identified wounds. They were instructed on ensuring skin assessments were completed per assignment and documented. The facility ensured all identified skin alterations had been addressed by the physician/nurse practitioner and responsible party was completed and documented. Nurse managers were instructed of their responsibility to complete skin assessments/wound assessments and notifications when the treatment nurse is unavailable. An in-service dated 9/30/20 for charge nurses, medication aides, and CNAs indicated: -Skin assessments must be completed by the charge nurse on all new admissions and readmissions weekly if a treatment nurse is not scheduled, and with a change in condition or worsening of a skin issue/wound. -Treatment nurse will complete all skin assessments. -Physician and responsible party must be notified of all new skin issues/wounds and change in condition or worsening of a skin issue/wound. -If physician does not answer, document attempts and notify theDON and medical director. -Treatment orders must be put in place along with interventions the day new skin issues/changes are noted. -All skin assessments must include measurement and descriptions/characteristics and all must be documented in the nurses' notes. -all skin issues noted by a CNA must be reported to a charge nurse and documented under the alert tab in their documentation -Theraworks (barrier cream) after each incontinent episode -Turn and reposition resident's every 2 hours, and provide incontinent care every 2 hours -Get residents up out of bed to increase mobility During an interview on 10/1/20 at 9:55 a.m., the DON said 100% of the skin assessments were completed on 9/30/20. She said the corporate nurse educated her and the nurse managers on ensuring skin assessments were completed and accurate, and physician and responsible party notification were completed and accurate. She said she was interviewing for a treatment nurse, but until one was hired, the nurses were educated on assessments and notification and documentation. During interviews on 10/1/20 from 11:40 a.m. to 12:15 p.m. 4 charge nurses (who work all shifts) said they had been in-serviced on assessing wounds by measuring and describing them and notifying the physician/nurse practitioner and responsible party of new and changing wound. They said they were to document all assessments including measurements, descriptions, physician and responsible party notification in the nursing notes They were told to ensure all wounds had a treatment order. One medication aide, and 4 CNAs (who work all shifts) said they were in-serviced to notify the charge nurse and complete an alert in their computer documentation of any new or changing skin issues. They said they were also reminded about turning and repositioning the residents. The facility's skin report dated 9/30/20 indicated all residents in the facility had been completed except one who refused. On 10/1/20 at 12:30 p.m., the administrator, DON and Regional nurse consultant were informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as pattern due the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure treatment and care was provided based on the comprehensive care plan and in accordance with professional standards of practice for 1 of 6 residents reviewed for quality of care. (Resident #5) The facility did not monitor Resident #5's toes on her left foot and immediately report changes to her physician as indicated by the comprehensive care plan. The facility did not assess, measure, or document a description of Resident #5's left foot toes. The facility did not schedule an appointment with a specialist (as ordered by the physician) related to Resident #5's complaint of losing feeling in her feet. Resident #5 was admitted to the hospital 25 days later with dry gangrene (caused when blood flow is impaired causing the tissue to dry up, be brown to purplish-blue to black in color and often falls off) to her second and third left toes. This failure could place residents at an increased risk for complications due to delayed physician intervention. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 9/29/20. While the IJ was removed on 10/1/20, the facility remained out of compliance at actual harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: Physician orders [REDACTED].#5 admitted [DATE], was [AGE] years old, and had [DIAGNOSES REDACTED]. A care plan dated 7/11/19 for Resident #5 indicated the resident was at risk for pressures ulcers due to immobility. A care plan intervention indicated a skin assessment was to be completed upon admission and at least weekly thereafter. An MDS assessment dated [DATE] indicated Resident #5 had severe cognitive impairment and required extensive to total assistance with all activities of daily living. There were no skin issues identified on the assessment, but the resident was at risk for developing pressure ulcers. A skin assessment dated [DATE] indicated Resident #5 had no skin issues. A skin assessment dated [DATE] completed by LVN A indicated Resident #5 had a stage II pressure injury on the 2nd toe of her left foot. The assessment did not include a description or measurements of the pressure injury. There was no documentation of physician notification. The August 2020 MAR indicated [REDACTED]. During an interview on 9/22/20 at 10:18 a.m., the DON said LVN A got an order for [REDACTED]. A physician order [REDACTED].#5 was to receive skin prep to her left toe wounds daily. A care plan updated 9/1/20 indicated Resident #5 had wounds on her left toes. The care plan interventions indicated the facility was to monitor the areas for increased breakdown or signs and symptoms of infection, and report any changes to the physician. The care plan indicated the facility was to assess the resident's skin weekly and record findings in the clinical record. A nursing progress note dated 8/21/20 at 9:42 p.m. completed by LVN A indicated Resident #5 complained of a loss of sensation to her feet. LVN A contacted the NP for the medical director and received an order to get an appointment with a physician at a local bone and joint clinic. The note indicated LVN A called and left a message at the clinic and would follow up on Monday. During an interview on 9/22/20 at 10:51 a.m., LVN A said she did not recall anything about Resident #5's toes. She did not recall completing the assessment on Resident #5's toes on 8/20/20 or the resident complaining of a loss of sensation to her toes on 8/21/21. She did not remember if she called the physician regarding the resident's toes and did not recall getting an order for [REDACTED].>The nursing progress notes from 8/21/20 to 9/22/20 did not contain documentation of Resident #5 having an appointment at a local bone and joint clinic. During an interview on 9/29/20 at 4:11 p.m., the DON said she was not aware of the referral to the local bone and joint clinic for Resident #5. She said there should have been an order written [REDACTED]. She said the facility evacuated on 8/25/20 due to a hurricane and the residents returned to the facility on [DATE]. She said the referral got missed. The clinical record for Resident #5 did not contain a skin assessment for the week of 8/23/20. A hospital history and physical dated 8/27/20 (while evacuated due to hurricane) indicated Resident #5 had issues that appeared to be a blister with rupture and desquamation (peeling) of the epidermis (skin) on the 3rd and 4th toes on the left foot. The history and physical indicated the resident's feet did not have swelling. During an interview on 9/21/20 at 1:08 p.m., Resident #5's daughter said the facility did not make the family aware of any concerns about the resident's toes on her left foot. She said while the facility was evacuated due to the hurricane, Resident #5 had to go to the hospital. She said her sister was able to see Resident #5 at the hospital on [DATE] and the resident's toes were a reddish purple color, but there was no open wound. She said the family was never told the resident's toes worsened. A skin assessment dated [DATE], completed by LVN C indicated Resident #5 had a wound to her left toes. The assessment did not contain the number or wounds, exact location, description or measurements of the wounds. The assessment did not indicate the physician or responsible party was notified of the wound. The September 2020 MAR indicated [REDACTED]. During an interview on 9/21/20 at 1:08 p.m., Resident #5's daughter said her sister was watching the camera in her mother's room on 9/10/20 when staff closed the curtain to transfer the resident to bed. The sister heard Resident #5 tell staff to watch her foot. She then heard the resident scream. Resident #5's daughter said she called the facility and spoke with LVN B. She said LVN B went to her mother's room and touched the resident's toes and said her mother did not yell out. Resident #5's daughter said she talked to LVN B on 9/11/20 (Friday) about calling the physician. She said LVN B told her Resident #5's physician was bad about not returning calls on the weekend, but she would pass it on to LVN C to call Monday. She said she did not get a call from LVN C on Monday (9/14/20) so she called LVN C on Tuesday (9/15/20). She said LVN C told her she had not received any messages from LVN B and there was nothing documented in the chart. The daughter said LVN C called the physician and Resident #5 was sent to the hospital. The daughter said the physician at the hospital told her Resident #5's toes were dead and there was no circulation to her left foot. She said the family was told by the cardiologist and the foot doctor at the hospital Resident #5 was not a candidate for surgery. During an interview on 9/18/20 at 12:05 p.m., LVN B said the first time she saw Resident #5's foot was when the daughter called and asked her to go look at the resident's toes on 9/11/20. She said the resident's toes were purple in color. She said the resident did not yell out in pain when she touched her toes. She said she did not call the physician or document in the Resident's medical record about the resident's toes. A skin assessment dated [DATE] (11 days after the last documented assessment) completed by LVN F indicated Resident #5 had a wound to her left toes. The assessment did not contain the number of wounds, exact location, a description, or measurements of the wound. The assessment did not indicate the physician was notified of the wound. During an interview on 9/28/20 at 8:02 p.m., LVN F said she did not measure or describe the wounds on Resident #5's left foot because the DON had been measuring all wounds. She said she assumed the DON was completing the assessments and measuring the wound on Resident #5's foot. She said when she completed the assessment on 9/12/20, the toes just looked bruised. She said there were no open wounds and the toes were not black. During an interview on 9/17/20 at 4:40 p.m., CNA G said she worked the weekend before Resident #5 went to the hospital (9/12/20-9/13/20). She said the two middle toes on the resident's left foot looked like the skin was coming off. She said the toes were dark purple. She said before the evacuation it just looked like a scrape. She said she reported the condition of the resident's toes to a nurse but could not remember who she reported to. During an interview on 9/22/20 at 11:25 a.m., LVN C said the day before Resident #5 was sent to the hospital (9/14/20) her toes just had a scab and were a little pink. She said she should have described them more in the skin assessment. She said on 9/15/20 when she talked to Resident #5's daughter, she told the daughter she had not received any messages from LVN B and there was no note in her chart. LVN C said she went to look at Resident #5's toes on 9/15/20. She said the resident's left foot was swollen and a little red, and the 2nd and 3rd toes were black. She said she notified the physician and the resident was sent to the emergency roiagnom on [DATE]. She said they were using skin prep on her left toes. She said she could use a little more training on assessments. Nursing progress notes dated 8/20/20 through 9/15/20 for Resident #5 did not include any evidence of physician notification regarding Resident #5's toes until the resident was sent to the hospital on [DATE]. Physician/Nurse Practitioner progress notes dated 9/10/20 did not mention any skin issues. During an interview on 9/28/20 at 3:42 p.m., the nurse practitioner for Resident #5's physician said she was not the one the facility would call for orders or notifications. She said she spoke with the physician's nurse who fields his calls. She said the nurse told her she had not received any calls about Resident #5's toes until 9/15/20 when she was sent to the hospital. During an interview on 9/22/20 at 10:18 a.m., the DON said the LVN who usually did the wound care and assessments of wounds had been out since July. She said she and LVN C had been helping with skin assessments. She said the charge nurses were supposed to do the weekly skin assessments of the residents without wounds and report any new wounds to her (DON). She said she was not aware of the wound on Resident #5's toes until 9/15/20. The DON said they had a wound care physician who made rounds weekly but Resident #5 was not referred to the wound care physician because she was not aware of the resident's wounds. She said LVN B should have called her and the medical director if a physician was not returning calls. She said LVN C told her Resident #5's toes did not look black the day before she went to the hospital. She said the charge nurses were supposed to complete weekly skin assessments on all residents and were to include measurements and descriptions of any wounds. An emergency room nursing note dated 9/15/20 indicated left toe infection, extremity pain/Swelling nontraumatic. The physician's emergency room visit notes dated 9/15/20 indicated Resident #5 had moderate to severe [MEDICAL CONDITION]. The physical exam indicated Resident #5 had dry gangrene (caused when blood flow is impaired causing the tissue to dry up, be brown to purplish-blue to black in color and often falls off) of the second and third toes with [DIAGNOSES REDACTED] (redness), mild swelling, and tenderness. A Wound Care Consultation note dated 9/17/20 indicated Resident #5 was on [MEDICATION NAME] 875 mg every 12 hours and recommended Hyperbaric oxygen therapy (used to treat wounds that will not heal) for her foot ischemia (inadequate blood supply). An undated Skin Management System indicated 2. Routine weekly checks will be completed on the Skin Observation Tool on every resident; if skin is intact it will be noted as such. If a new pressure sore is noted, a Weekly Wound Observation Form will be started. The facility's undated Skin Management System indicated 10. Keep open lines of communication with physicians, families, and residents regarding status of wounds. The administrator and DON were notified on 9/29/20 at 4:18 p.m. an IJ situation was identified due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 10/1/20 at 5:21 p.m. and included: Plan of IJ Removal for (Facility) 9/29/2020 Quality of Care and Notification Plan of Action Head-to-toe skin assessments were completed on 9/16/2020 on all residents (2 refusals but completed on 9/25/2020 & 9/23/2020) by Nursing Management. Head-to-toe skin assessments were completed the week of 9/21/2020 on all residents. Head-to-toe skin assessments were completed 9/30/2020 on all residents. Licensed Nurses were provided in-service education on 9/16/2020 and 9/30/2020 by DON/designee which includes: 1. Proper skin assessments on admission, weekly, and with a change of condition. 2. Identifying a change in condition of the wound and reporting it to attending physician and responsible party. 3. Daily wound monitoring, weekly assessment per schedule, and document the assessment on PCC. 4. Receiving orders on wounds from attending physician and ensure orders were carried out timely. 5. All assessments must include measurement and description of the wound. Nursing Administration initiated in-service education with Charge Nurses on 9/29/2020 about documenting any outside referrals in nurses notes and writing physician order. After referral is documented the Nursing Administration will pull the 24-hour report to review all new order in clinical meeting and follow-up accordingly. Regional Director of Clinical Operations performed in-service education on 9/30/2020 with DON and ADON on monitoring skin assessments, wound assessments, MD/RP notifications, and wound documentation. Nursing Management will assume performing responsibility of treatment nurse's role by completing skin assessments, wound assessment, and wound care until treatment nurse returns from leave of absence. Validation/Monitoring Tools The skills validation for skin/wound assessments to be conducted by the DON with all the Nursing Management to ensure competency by 9/30/2020. 24-hour report will be reviewed in clinical meeting by DON/Designee to identify any new skin concerns and to ensure assessment was completed, order obtained for wound, and MD/RP notification. New order listing report will be reviewed in clinical meeting by DON/Designee to ensure referral follow-up. UDA tool will be utilized by DON/Designee to audit skin assessments for completion. QAPI The Administrator held an Ad hoc QAPI meeting on 9/16/2020 to develop a plan of action related to skin integrity, documentation, and family/MD notification. The Administrator will review the action plan developed related to skin integrity, documentation, and family/MD notification monthly during the QAPI meeting. On 10/1/20 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: An in-service dated 9/30/20 indicated all nurse managers were trained on skin assessments, wound assessments/documentation, responsible party and physician notification, and ensuring a treatment is in place for all identified wounds. They were instructed on ensuring skin assessments were completed per assignment and documented. The facility ensured all identified skin alterations had been addressed by the physician/nurse practitioner and responsible party was completed and documented. Nurse managers were instructed of their responsibility to complete skin assessments/wound assessments and notifications when the treatment nurse is unavailable. An in-service dated 9/30/20 for charge nurses, medication aides, and CNAs indicated: -Skin assessments must be completed by the charge nurse on all new admissions and readmissions, weekly if a treatment nurse is not scheduled, and with a change in condition or worsening of a skin issue/wound. -Treatment nurse will complete all skin assessments. -Physician and responsible party must be notified of all new skin issues/wounds and change in condition or worsening of a skin issue/wound. -If physician does not answer, document attempts and notify the DON and medical director. -Treatment orders must be put in place along with interventions the day new skin issues/changes are noted. -All skin assessments must include measurement and descriptions/characteristics and all must be documented in the nurses' notes. -all skin issues noted by a CNA must be reported to a charge nurse and documented under the alert tab in their documentation -Theraworks (barrier cream) after each incontinent episode -Turn and reposition resident's every 2 hours, and provide incontinent care every 2 hours -Get residents up out of bed to increase mobility During an interview on 10/1/20 at 9:55 a.m., the DON said 100% of the skin assessments were completed on 9/30/20. She said the corporate nurse educated her and the nurse managers on ensuring skin assessments were completed and accurate, and physician and responsible party notification were completed and accurate. She said she was interviewing for a treatment nurse, but until one was hired, the nurses were educated on assessments and notification and documentation. During interviews on 10/1/20 from 11:40 a.m. to 12:15 p.m. 4 charge nurses (who work all shifts) said they had been in-serviced on assessing wounds by measuring and describing them and notifying the physician/nurse practitioner and responsible party of new and changing wound. They said they were to document all assessments including measurements, descriptions, physician and responsible party notification in the nursing notes. They were told to ensure all wounds had a treatment order. One medication aide, and 4 CNAs (who work all shifts) said they were in-serviced to notify the charge nurse and complete an alert in their computer documentation of any new or changing skin issues. They said they were also reminded about turning and repositioning the residents. The facility's skin report dated 9/30/20 indicated all residents in the facility had been completed except one who refused. On 10/1/20 at 12:30 p.m., the administrator, DON and Regional nurse consultant were informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as pattern due the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures to ensure 1 of 10 residents reviewed for neglect was free from neglect. (Resident #1) The facility did not serve Resident #1 a mechanical soft diet as ordered by the physician on [DATE] during the evening meal. The resident received a regular piece of chicken and the CNA cut the chicken into pieces. There were no licensed nursing staff available in the dining room to check the resident trays before the resident was served. Resident #1 ate the piece of chicken in the dining room and choked. CNA D tried to perform the [MEDICATION NAME] maneuver on the resident without success and pushed Resident #1 to the nursing station for help because he was choking. The resident was unresponsive and his blood pressure and pulse were unobtainable. Three LVNs did not recognize Resident #1 was choking, thought he was having a [MEDICAL CONDITION], and pushed him to his room. The resident was transferred to his bed and he died shortly after. This failure likely contributed to Resident #1's death on [DATE]. An Immediate Jeopardy was determined to have existed from [DATE] through [DATE]. This was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the beginning of the survey. This failure could place 33 residents with mechanical soft diets at risk for choking and death. Findings included: The facility's undated Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents indicated Each resident has the right to be free from .neglect . Physician orders [REDACTED].#1 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His diet order dated [DATE] was mechanical soft with ground meats and regular thin liquids. A Dysphagia Consultation dated [DATE] indicated Resident #1 had a [DIAGNOSES REDACTED]. The diet recommendations indicated: mechanical soft solids, chopped, downgrade to ground as needed, and may be ground meats, but chopped vegetables if cooked soft. The Care Plans dated [DATE] indicated Resident #1 required staff assistance for all ADLs and required supervision with eating. The resident was on a mechanical soft diet with ground meats and regular thin liquids. A Nutrition Quarterly Progress Note dated [DATE] indicated Resident #1's diet was mechanical soft. An MDS dated [DATE] indicated Resident #1's BIMS was 7 (severe impairment) and required supervision when eating. During an interview on [DATE] at 9:05 a.m., CNA D said Resident #1 was on a mechanical soft diet with chopped meat. She said Resident #1's meal ticket on his tray indicated his diet was mechanical soft with ground meat. She said when Resident #1 choked (on [DATE]), the nurses were not in the dining room. She said she knew he should not have the chicken if it was not ground and Resident #1 said he was not supposed to have the chicken if it was not ground. CNA D said she took Resident #1's tray back to the kitchen and asked for something else. She said the kitchen staff told her to cut up the chicken. She said she went back to the table and Resident #1 asked her to take the skin off the chicken. She said she took the skin off the chicken and then cut the chicken into 5 pieces. She said she used the fork and broke up 2 of the pieces and sort of shredded the 2 pieces of chicken. She said she gave Resident #1 a spoon and went to another table to assist feeding other residents. She said she did not supervise Resident #1 at his table, but she could see Resident #1 from the other table. CNA D said she saw Resident #1 had his hand in the air and he was staring at her and pointing at his neck. She said she realized he was choking. She said she told the other aide to get the nurses. CNA D said she tried to perform the [MEDICATION NAME] manuever, but the resident was still choking. She said she realized the other nurses were not going to make it in time and told Resident #1 to raise up his feet and she pushed him down the hall. CNA D said she met LVN A and LVN C in the hall and told them Resident #1 was choking. She said she knew Resident #1 had passed before she left her shift at 10:00 p.m. on [DATE]. CNA D said she was trained on her duties, abuse and neglect prevention and reporting, and diets and diet textures/consistencies. She said she was trained during orientation and since the incident. Nursing notes, completed by LVN A, dated [DATE] at 6:25 p.m. indicated nurse assistants brought Resident #1 via his wheelchair from the dining area to the nursing station. Resident #1 was assessed with [REDACTED]. The resident was assisted to his room and 3 staff assisted him from his wheelchair to his bed. The notes indicated Resident #1 had general cyanosis all over his via the assessment and signs and symptoms of [MEDICAL CONDITION] activity ceased. The head of the resident's bed was raised for respiratory support and his lower extremities were elevated for blood pressure support as well. Resident #1's skin was cool and clammy to touch and he was non-responsive to physical and verbal stimuli. The notes indicated the resident's blood pressure was not obtainable and his apical pulse was absent. Resident #1's respirations ceased and they were unable to obtain a pulse oxygen saturation reading. At 6:30 p.m., the nurse practitioner returned the call with notification of above with verbal pronouncement of death per doctor at 6:30 p.m. Notified administrator, DON, and both of the ADONs of above. During an interview on [DATE] at 12:53 a.m., LVN A said she was not present in the dining room when Resident #1 was served his supper meal on [DATE]. She said she assisted another resident from the dining room at that time. She said she was coming back up the hall and 2 CNAs said Resident #1 had choked. She said Resident #1's hands were purple and he looked like he was having a [MEDICAL CONDITION]. She said there was no cyanosis. She said LVN C said he was having a [MEDICAL CONDITION]. She said he was not responsive in the hallway. LVN A said she did not ask what Resident #1 might have choked on. She said she did not talk to the aides. She said she did not perform the [MEDICATION NAME] maneuver on Resident #1 in the hallway when she first saw him. She said they took Resident #1 to his room via his wheelchair while LVN C went to check his DNR status. She said CNA M assisted Resident #1 to his bed and the resident was not responsive. LVN A said she looked in Resident #1's mouth, but didn't see anything. She said LVN B said there was a piece of chicken that looked like a piece of thread. She said she did not call the DON because she felt more comfortable calling ADON B. LVN A said she could not recall if she reported to ADON B that CNA A said Resident #1 choked. She said LVN B was assigned to the dining room on [DATE] and LVN B should have checked Resident #1's meal ticket. She said the nurses would alternate who went to the dining room for meal. During an interview on [DATE] at 3:27 p.m., LVN C said CNA A said Resident #1 choked, but he didn't look like he was choking. She said Resident #1 looked like he was having a [MEDICAL CONDITION]. She said she grabbed the crash cart and checked on Resident #1's DNR status before going to the resident's room. LVN C said Resident #1 was in bed when she arrived in the room. She said Resident #1 was not gurgling or coughing and he did not have a blue face or blue hands. She said Resident #1 was having jerking movements. She said Resident #1 did not have a history of [MEDICAL CONDITION] and was not on any [MEDICAL CONDITION] medications. LVN C said she was working as the medication nurse and was not as assigned in the dining room. On [DATE] at 11:58 a.m. the investigator left a message on LVN B's voicemail to return call and interview. LVN B did not respond to calls from the investigators on for an interview. A statement obtained by LVN B (obtained [DATE], but dated [DATE] -the date of the incident) indicated she was not in the dining room at the start of the incident because she was bringing trays to the residents who were not in the dining room. LVN B indicated CNA H came around the corner on Hall 200 hollering Resident #1 choked, something's wrong. LVN A, standing in the hall, called out to LVN B and LVN C and all 3 of the nurses met CNA D in the hall. LVN A went around Resident #1's wheelchair to perform the [MEDICATION NAME] maneuver on Resident #1. LVN B indicated LVN A stated I think it's a [MEDICAL CONDITION]. The statement indicated Resident #1 was sitting in the wheelchair with his hands and lower arms in his lap and his upper body was convulsing. LVN B indicated Resident #1's hands were blue, his face was pale, and his eyes were rolled back. The shaking lasted for ,[DATE] seconds and then the resident went limp. CNA M assisted Resident #1 to his bed then left the room. The statement indicated the nurses sat patient on side of bed to attempt [MEDICATION NAME] maneuver once again but patient was unresponsive, laid patient on back, head of bed raised The resident had no respirations and his vital signs were unable to be obtained with attempts from all 3 nurses. LVN B indicated she attempted to suction Resident #1's mouth and was unable to retrieve anything. The physician was notified and Post mortem care performed by 2 nurses. During an interview on [DATE] at 2:00 p.m., CNA M said he was in the hall picking up trays when CNA H ran to the nursing station. He said he went to see what was happening and saw Resident #1 bent over in his wheelchair. He said Resident #1 was not moving. He said he assisted the nurses and brought Resident #1 to his room and put him on his bed. CNA M said Resident #1 was unresponsive. He said LVN C brought the crash cart and suctioned Resident #1. He said they got out a small piece of meat that had not been chewed. CNA M said one of the nurses (he could not recall who) checked Resident #1's heart beat and it was faint. He said one of the nurses (he could not recall which one) performed the [MEDICATION NAME] maneuver on Resident #1 and then checked him again. He said he went and got a stethoscope off the nursing cart and the nurses checked Resident #1 again. CNA M said he left the resident's room and then the nurses came out of the room crying. He said he knew Resident #1 had passed. He said the nurses were supposed to be in the dining room during meal service. A statement obtained by CNA H dated [DATE] indicated she was a witness to Resident #1 in the dining area eating his food on [DATE]. CNA H indicated she thought Resident #1 was choking, so she ran to tell the nurses. She indicated another aide rolled Resident #1 in his wheelchair to the nursing station and the nurses took him and proceeded with the situation. The statement indicated when the nurses came out of Resident #1's room, they said he had a [MEDICAL CONDITION] and announced he was dead. She said there were no licensed nursing staff in the dining room on [DATE]. During an interview on [DATE] at 11:42 a.m., DS A said on [DATE] she put a chicken salad sandwich on the tray for Resident #1. She said she was aware Resident #1's diet was mechanical soft with ground meat. She said DS B took the sandwich off and told her to put a piece of chicken on the tray with mashed potatoes and peas. She said the tray was sent out to Resident #1. She said the CNA D came back to the door and said Resident #1 could not eat the chicken and DS B told her to cut it up and gave the tray back to CNA B. She said CNA D said there was no nurse in the dining room, but to start serving anyway. DS A said after the meal service she found out Resident #1 died . She said she went back into the dining room and DS B said she was sorry she told her to give Resident #1 the piece of chicken. She said the next morning on [DATE], she went to work and was upset about the incident involving Resident #1 and called the FSD to set up a meeting with the administrator. She said she did not tell the FSD why she wanted to have the meeting. She said the meeting never happened with the administrator and she called CNA S on [DATE] and asked her to set up a meeting with the AIT. She said there was a 3-way call on [DATE] with the AIT and she told the AIT she gave Resident #1 a piece of chicken after the direction form DS B. She said she came back to work on [DATE] and was told the DON wanted to speak to her. She said she told the DON that DS B told her to give Resident #1 the chicken and there were no nurses in the dining room for the meal service on [DATE]. During an interview on [DATE] at 12:40 p.m., DS B said she did not recall seeing any nurses in the dining room during supper meal service. She said she told DS A to fix the chicken for Resident #1, but she did not know what was on the meal ticket. She said she was not aware Resident #1 choked. She said DS A did not say Resident #1's food was supposed to be mechanical soft. During an interview on [DATE] at 8:00 a.m., CNA S said on [DATE] she arranged a 3-way call with DS A and the AIT. She said DS A reported what happened on [DATE] involving Resident #1. CNA S said she was not aware of the incident until [DATE]. She said the nurses were supposed to be in the dining room for all meals. She said the nurses were supposed to check the meal tickets prior to giving the residents their meal trays and the meal tickets were always on the trays. She said all staff were trained on abuse and neglect prevention, reporting, and resident diets. She said DS A should have reported the incident to the administrator. During an interview on [DATE] at 1:17 p.m., the FSD said Resident #1's diet was mechanical soft with ground meat. She said the diet cards were printed out daily and placed on the trays prior to meal services. The FSD said DS B was supposed to know what was on the trays and read the residents' meal ticket to make sure it was the correct meal. She said DS A called her and said she wanted a meeting with the administrator. She said DS A did not say why she wanted to meet with the administrator. The FSD said the meeting did not occur. She said the nurses were supposed to be in the dining room during meal service and were supposed to check the trays prior to giving the trays to the residents. She said the staff were not supposed to serve the meals out of the kitchen until the nurses were in the dining room. She said all the kitchen staff were trained on abuse and neglect prevention and reporting, diets and diet textures during orientation and since the incident. During an interview on [DATE] at 5:20 p.m., the dietary manager said all mechanical soft diets included ground meat. During an interview on [DATE] at 5:15 p.m., the DON said the nurses should have been in the dining room during meal service on [DATE]; however, the nurses were not. She said she was informed by LVN B that she (LVN B) suctioned Resident #1 and a piece of chicken came out of his mouth. She said Resident #1 would sometimes eat in the dining room and sometimes eat at the nursing station. She said Resident #1 would eat too fast without supervision. During an interview on [DATE] at 10:05 a.m., ADON B said no one reported to her of Resident #1 choking on [DATE]. She said on [DATE] LVN A reported Resident #1 died after a [MEDICAL CONDITION]. ADON B said the Monday or Tuesday after Resident #1 died , the DON asked her about Resident #1 choking and she told the DON that it was not reported to her that Resident #1 choked. She said she was not aware of Resident #1 choking while eating until after the AIT reported it to the administrator on [DATE]. During an interview on [DATE] at 8:23 a.m., ADON A said she received a text from ADON B on [DATE] that Resident #1 died of natural causes. She said on [DATE] there were rumors that Resident #1 choked and she told the DON. She said the DON asked ADON B who said that it was reported he had a [MEDICAL CONDITION] and he had passed. She said the DON did not investigate further. She said nothing else was said about it until DS A reported to the AIT that she had served Resident #1 A piece of chicken. She said she read the chart on [DATE] and the charting did not match what the nurses said about [MEDICAL CONDITION] activity being confirmed by 3 LVNs. She said she did not know why 911 was not called. She said she could not understand why the LVNs would suction when they said Resident #1 had a [MEDICAL CONDITION]. She said the nurses said they did not do a [MEDICATION NAME]. She said LVN A said she suctioned but it was not in her statement. She said LVN B said the CNA said Resident #1 was choking and she went around the chair to do a [MEDICATION NAME] in the hall. She said that once the LVNs got Resident #1 in the room and on his bed a [MEDICATION NAME] was performed and nothing came out. She said LVN B said he was suctioned and nothing was removed. She said LVN C said he was suctioned and a string of chicken came out. She said she was present at LVN B's exit interview. She said LVN B admitted she suctioned a piece of un-chewed chicken and held two fingers apart and indicated approximately a ,[DATE] - ,[DATE] inch piece of chicken was suctioned out of Resident #1's mouth. She said LVN B said she suctioned Resident #1 out of curiosity. She said LVN B admitted she was not in the dining room and that she was walking trays to the residents in their rooms. She said the nurses were supposed to be in the dining room for meal service. She said Resident #1 would eat in the dining room with supervision. During an interview on [DATE] at 10:44 a.m., the DON said the day after the incident, on [DATE], ADON A came to the office and said some of the aides were arguing about what was served for supper to Resident #1. She said she asked ADON B what the staff were arguing about and ADON B said it was nothing major and she would talk to the administrator. She said ADON B came into her office on [DATE] and said the incident involving Resident #1 was nothing major. The DON said if she had known Resident #1 choked, she would investigated that day. She said she asked LVN A and LVN B why did they not call 911 and they responded because Resident #1 was DNR status. She said she LVN A and LVN B why an incident report was not completed for Resident #1 and they responded because it was a [MEDICAL CONDITION]. She said all the nurses said Resident #1 exhibited the signs and symptoms of [MEDICAL CONDITION]. She said she was not aware the CNAs reported to the nurses that Resident #1 choked. The DON said she was not aware Resident #1 choked on a piece of chicken until [DATE] when the administrator told her the dietary manager reported Resident #1 may not have had a [MEDICAL CONDITION]. During an interview on [DATE] at 8:46 a.m., the AIT said she became aware on [DATE] of the incident with Resident #1. She said CNA S called her and reported that DS A wanted to talk to her (AIT) about the food she served to Resident #1. She said DS A said it was bothering her. She said DS A said she tried to talk to her supervisor and arrange a meeting with the administrator, but the meeting had not occurred. She said DS A said she prepared Resident #1 a chicken salad sandwich and DS B told her to take away the sandwich and give him the piece of chicken. The AIT said she did not know if CNA D cut up the piece of chicken. She said she did not report the incident to the administrator until [DATE]. She said she did not think it was reportable because she did not know Resident #1 had choked from the piece of chicken. The AIT said she was trained on abuse and neglect prevention and the policy for reporting prior to and after the incident. During an interview on [DATE] at 11:04 a.m., the administrator said he found out about Resident #1's possible choking on [DATE] from the AIT. The administrator said he started an investigation upon becoming aware of the incident on [DATE]. He said he told ADON B to call in LVN A and he then told the DON about the staff reporting they served the chicken and Resident #1 may have choked. He said the incident involving Resident #1 was not reported as required. He said he informed the family on [DATE]. He said when he was not in the facility the staff should have reported to the DON. The administrator said the cook had training and she should have served what was on the meal ticket. The facility Investigation Report dated [DATE] indicated the administrator was informed of Resident #1's incident on [DATE] and he reported to the state agency on [DATE] at 10:20 pm. During an interview on [DATE] at 9:10 a.m., the administrator said he was the Abuse Prevention Coordinator and the DON was the designee when he was not available. He said LVNs A and B were suspended on [DATE] and terminated on [DATE]. The administrator said LVN C, CNA D, DS A, and DS B were suspended on [DATE], received written warnings, and in-serviced per the facility's corrective action plan dated [DATE]. On [DATE] at 3:23 p.m., the administrator was informed that an Immediate Jeopardy was determined to have existed from [DATE] through [DATE]. The Immediate Jeopardy was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the beginning of the survey. The Immediate Jeopardy was removed on [DATE] because, prior to surveyor entrance, the facility had implemented action plans on [DATE], retrained staff from [DATE] through current, and the staff was aware of reporting and prevention measures. During an interview on [DATE] at 5:00 p.m., the administrator said he suspended the AIT, DON, ADON A, and ADON B. The facility's action plan dated [DATE] included a schedule of all administration staff monitoring all meals through [DATE]. During observations on [DATE] at 8:57 a.m. and 5:30 p.m. and on [DATE] at 7:30 a.m. and 11:30 a.m., there were nurses in the dining room for all meals, all trays were checked prior to sending to the residents, and all trays examined by the investigator had the required meal and correct texture per the meal ticket and physician orders. The facility's corrective actions taken from [DATE] and ongoing included: *In-service nursing staff on completing an incident report on all incidents identified including choking; witnessed or reported. *Nursing would monitor residents during meal times to ensure safety of residents. *Incidents reports would be reviewed during clinical meeting to identify choking residents. *Speech therapy to be notified of all incidents involving choking. *Interventions to be put in place to appropriately address the reason for choking and care plans updated as needed. The facility's in-services dated [DATE] indicated the following were completed: *nursing staff should prepare an incident report to document unusual and/or significant events or emergencies involving individuals or residents (including choking or strangling). *staff will review first aid for choking and return demonstration with proficiency check off; handout given to all employees. *all staff were trained on the abuse/neglect policy; content included review of who was the abuse coordinator, reporting abuse and neglect immediately, and not to assume incidents were reported to the abuse coordinator. The facility's in-service dated ,[DATE]-,[DATE] conducted by the Dietary Services included proper diet consistencies, therapeutic diets, and liquid consistencies, proper methods of writing diet orders and how to convert diets when residents enter the facility, properly identify regular, cut up, mechanical soft and puree trays, communication with therapy on aspiration risk and/or episodes of choking/aspiration, and demonstration of properly cutting up residents' meats. The facility's in-services dated [DATE] indicated the following were completed: *all nurses would have CPR training updated within 30 days of [DATE]. *staff were advised of the residents on thickened liquids and therapeutic diets and the facility's policies for thickened liquids and therapeutic diets. *nurses would complete communication forms only if there was a physician order [REDACTED]. Nurses were to include all three parts when writing/clarifying diet orders: 1. Therapeutic Diet, 2. Solid Texture (regular, mechanical soft with ground, puree), and 3. Liquid Texture. *the process for nurses to write diet orders. During an interview on [DATE] at 4:00 p.m. the dietary manager said there were 33 residents with mechanical soft diets.

Based on interview and record review, the facility failed develop and implement their written policies and procedures to prohibit mistreatment and neglect for 1 of 10 residents reviewed for neglect. (Resident #1) The facility did not report an incident immediately to the administrator when Resident #1 choked when he was served the wrong diet order on [DATE] during the evening meal. Resident #1 died shortly after. The DON was informed on [DATE] the resident died after having [MEDICAL CONDITION] activity and there were rumors of the resident choking during the meal service. The AIT was made aware of the incident on [DATE] by another staff. The facility did not investigate the incident until the administrator became aware of Resident #1 choking to death until [DATE]. An Immediate Jeopardy was determined to have existed from [DATE] through [DATE]. This was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the beginning of the survey. This failure could place the 33 residents who received mechanical soft diets at risk of mistreatment and neglect. Findings included: The facility's undated Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents indicated Each resident has the right to be free from .neglect . Physician orders [REDACTED].#1 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His diet order dated [DATE] was mechanical soft with ground meats and regular thin liquids. A Dysphagia Consultation dated [DATE] indicated Resident #1 had a [DIAGNOSES REDACTED]. The diet recommendations indicated: mechanical soft solids, chopped, downgrade to ground as needed, and may be ground meats, but chopped vegetables if cooked soft. The Care Plans dated [DATE] indicated Resident #1 required staff assistance for all ADLs and required supervision with eating. The resident was on a mechanical soft diet with ground meats and regular thin liquids. A Nutrition Quarterly Progress Note dated [DATE] indicated Resident #1's diet was mechanical soft. An MDS dated [DATE] indicated Resident #1's BIMS was 7 (severe impairment) and required supervision when eating. During an interview on [DATE] at 9:05 a.m., CNA D said Resident #1 was on a mechanical soft diet with ground meat. She said Resident #1's meal ticket on his tray indicated his diet was mechanical soft with ground meat. She said when Resident #1 choked (on [DATE]), the nurses were not in the dining room. She said she knew he should not have the chicken if it was not ground and Resident #1 said he was not supposed to have the chicken if it was not ground. CNA D said she took Resident #1's tray back to the kitchen and asked for something else. She said the kitchen staff told her to cut up the chicken. She said she went back to the table and Resident #1 asked her to take the skin off the chicken. She said she took the skin off the chicken and then cut the chicken into 5 pieces. She said she used the fork and broke up 2 of the pieces and sort of shredded the 2 pieces of chicken. She said she gave Resident #1 a spoon and went to another table to assist feeding other residents. She said she could see Resident #1 from the other table. CNA D said she saw Resident #1 had his hand in the air and he was staring at her and pointing at his neck. She said she realized he was choking. She said she told the other aide to get the nurses and attempted to perform the [MEDICATION NAME] maneuver without success. She said she realized the other nurses were not going to make it in time and told Resident #1 to raise up his feet and she pushed him down the hall. CNA D said she met LVN A and LVN C in the hall and told them Resident #1 was choking. She said she knew Resident #1 had passed before she left her shift at 10:00 p.m. on [DATE]. CNA D said she was trained on her duties, abuse and neglect prevention and reporting, and diets and diet textures/consistencies during orientation and since the incident. Nursing notes, completed by LVN A, dated [DATE] at 6:25 p.m. indicated nurse assistants brought Resident #1 via his wheelchair from the dining area to the nursing station. Resident #1 was assessed with [REDACTED]. The resident was assisted to his room and 3 staff assisted him from his wheelchair to his bed. The notes indicated Resident #1 had general cyanosis all over his via the assessment and signs and symptoms of [MEDICAL CONDITION] activity ceased. Resident #1's skin was cool and clammy to touch and he was non-responsive to physical and verbal stimuli. The notes indicated the resident's blood pressure was not obtainable and his apical pulse was absent. Resident #1's respirations ceased and they were unable to obtain a pulse oxygen saturation reading. At 6:30 p.m., the nurse practitioner returned the call with notification of above with verbal pronouncement of death per doctor at 6:30 p.m. Notified Administrator, DON, and both of the ADONs of above. During an interview on [DATE] at 12:53 a.m., LVN A said she was not present in the dining room when Resident #1 was served his supper meal on [DATE]. She said she was coming back up the hall and 2 CNAs said Resident #1 had choked. She said Resident #1's hands were purple and he looked like he was having a [MEDICAL CONDITION]. She said LVN C said he was having a [MEDICAL CONDITION]. She said they took Resident #1 to his room via his wheelchair while LVN C went to check his DNR status. She said CNA M assisted Resident #1 to his bed and the resident was not responsive. LVN A said she looked in Resident #1's mouth, but didn't see anything. She said LVN B said there was a piece of chicken that looked like a piece of thread. She said she did not call the DON because she felt more comfortable calling ADON B. LVN A said she could not recall if she reported to ADON B that CNA A said Resident #1 choked. During an interview on [DATE] at 3:27 p.m., LVN C said CNA A said Resident #1 choked, but he didn't look like he was choking. She said Resident #1 looked like he was having a [MEDICAL CONDITION]. She said Resident #1 was having jerking movements. She said Resident #1 did not have a history of [MEDICAL CONDITION]. LVN C said she was working as the medication nurse and was not as assigned in the dining room. On [DATE] at 11:58 a.m. the investigator left a message on LVN B's voicemail to return call and interview. LVN B did not respond to calls from the investigators on for an interview. A statement obtained by LVN B (obtained [DATE], but dated [DATE] -the date of the incident) indicated she was not in the dining room at the start of the incident. LVN B indicated CNA H came around the corner on Hall 200 hollering Resident #1 choked, something's wrong. LVN A, standing in the hall, called out to LVN B and LVN C and all 3 of the nurses met CNA D in the hall. LVN A went around Resident #1's wheelchair to perform the [MEDICATION NAME] maneuver on Resident #1. LVN B indicated LVN A stated I think it's a [MEDICAL CONDITION]. The statement indicated Resident #1 was sitting in the wheelchair with his hands and lower arms in his lap and his upper body was convulsing. LVN B indicated Resident #1's hands were blue, his face was pale, and his eyes were rolled back. The shaking lasted for ,[DATE] seconds and then the resident went limp. CNA M assisted Resident #1 to his bed then left the room. The statement indicated the nurses sat patient on side of bed to attempt [MEDICATION NAME] maneuver once again but patient was unresponsive, laid patient on back, head of bed raised The resident had no respirations and his vital signs were unable to be obtained with attempts from all 3 nurses. LVN B indicated she attempted to suction Resident #1's mouth and was unable to retrieve anything. The physician was notified and Post mortem care performed by 2 nurses. During an interview on [DATE] at 2:00 p.m., CNA M said he was in the hall picking up trays when CNA H ran to the nursing station. He said he went to see what was happening and saw Resident #1 bent over in his wheelchair. He said Resident #1 was not moving. He said he assisted the nurses and brought Resident #1 to his room and put him on his bed. CNA M said Resident #1 was unresponsive. He said LVN C brought the crash cart and suctioned Resident #1. He said they got out a small piece of meat that had not been chewed. CNA M said he left the resident's room and then the nurses came out of the room crying. He said he knew Resident #1 had passed. A statement obtained by CNA H dated [DATE] indicated she was a witness to Resident #1 in the dining area eating his food on [DATE]. CNA H indicated she thought Resident #1 was choking, so she ran to tell the nurses. She indicated another aide rolled Resident #1 in his wheelchair to the nursing station and the nurses took him and proceeded with the situation. The statement indicated when the nurses came out of Resident #1's room, they said he had a [MEDICAL CONDITION] and announced he was dead. During an interview on [DATE] at 11:42 a.m., DS A said on [DATE] she put a chicken salad sandwich on the tray for Resident #1. She said she was aware Resident #1's diet was mechanical soft with ground meat. She said DS B took the sandwich off and told her to put a piece of chicken on the tray with mashed potatoes and peas. She said CNA D said there was no nurse in the dining room, but to start serving anyway. DS A said after the meal service she found out Resident #1 died . She said the next morning on [DATE], she went to work and was upset about the incident involving Resident #1 and called the FSD to set up a meeting with the administrator. She said she did not tell the FSD why she wanted to have the meeting. She said the meeting never happened with the administrator and she called CNA S on [DATE] and asked her to set up a meeting with the AIT. She said there was a 3-way call on [DATE] with the AIT and she told the AIT she gave Resident #1 a piece of chicken after the direction form DS B. She said she came back to work on [DATE] and was told the DON wanted to speak to her. She said she told the DON Resident #1 was given the incorrect texture for his chicken and he choked on it. During an interview on [DATE] at 8:00 a.m., CNA S said on [DATE] she arranged a 3-way call with DS A and the AIT and DS A reported what happened on [DATE] involving Resident #1. CNA S said she was not aware of the incident until [DATE]. She said all staff were trained on abuse and neglect prevention, reporting, and resident diets. She said DS A should have reported the incident to the administrator. During an interview on [DATE] at 1:17 p.m., the FSD said DS A called her and said she wanted a meeting with the administrator. She said DS A did not say why she wanted to meet with the administrator. The FSD said the meeting did not occur. She said all the kitchen staff were trained on abuse and neglect prevention and reporting, diets and diet textures during orientation and since the incident. During an interview on [DATE] at 10:05 a.m., ADON B said no one reported to her of Resident #1 choking on [DATE]. She said on [DATE] LVN A reported Resident #1 died after a [MEDICAL CONDITION]. ADON B said the Monday or Tuesday after Resident #1 died , the DON asked her about Resident #1 choking and she told the DON that it was not reported to her that Resident #1 choked. She said she was not aware of Resident #1 choking while eating until after the AIT reported it to the administrator on [DATE]. During an interview on [DATE] at 8:23 a.m., ADON A said she received a text from ADON B on [DATE] that Resident #1 died of natural causes. She said on [DATE] there were rumors that Resident #1 choked and she told the DON. She said the DON asked ADON B who said that it was reported he had a [MEDICAL CONDITION] and he had passed. She said the DON did not investigate any further. She said nothing else was said about it until DS A reported to the AIT that she had served Resident #1 a piece of chicken. She said she read the chart on [DATE] and the charting did not match what the nurses said about [MEDICAL CONDITION] activity being confirmed by 3 LVNs. She said she did not know why 911 was not called. She said LVN A said she suctioned the resident, but it was not in her statement. She said LVN B said the CNA said Resident #1 was choking and she went around the chair to perform the [MEDICATION NAME] maneuver in the hall. ADON A said LVN B said he was suctioned and nothing was removed. She said LVN C said Resident #1 was suctioned and a string of chicken came out. She said she was present at LVN B's exit interview. She said LVN B admitted she suctioned a piece of chicken and held two fingers apart and indicated approximately a ,[DATE] - ,[DATE] inch piece of chicken was suctioned out of Resident #1's mouth. During an interview on [DATE] at 10:44 a.m., the DON said the day after the incident, on [DATE], ADON A came to the office and said some of the aides were arguing about what was served for supper to Resident #1. She said she asked ADON B what the staff were arguing about and ADON B said it was nothing major and she would talk to the administrator. She said ADON B came into her office on [DATE] and said the incident involving Resident #1 was nothing major. The DON said if she had known Resident #1 choked, she would investigated that day. She said she asked LVN A and LVN B why did they not call 911 and they responded because Resident #1 was DNR status. She said she LVN A and LVN B why an incident report was not completed for Resident #1 and they responded because it was a [MEDICAL CONDITION]. She said all the nurses said Resident #1 exhibited the signs and symptoms of [MEDICAL CONDITION]. She said she was not aware the CNAs reported to the nurses that Resident #1 choked. The DON said she was not aware Resident #1 choked on a piece of chicken until [DATE] when the administrator told her the dietary manager reported Resident #1 may not have had a [MEDICAL CONDITION]. During an interview on [DATE] at 8:46 a.m., the AIT said she became aware on [DATE] of the incident with Resident #1. She said CNA S called her and reported that DS A wanted to talk to her (AIT) about the food she served to Resident #1. She said DS A said it was bothering her. She said DS A said she tried to talk to her supervisor and arrange a meeting with the administrator, but the meeting had not occurred. The AIT said DS A said she prepared Resident #1 a chicken salad sandwich and DS B told her to take away the sandwich and give him the piece of chicken. She said she did not report the incident to the administrator until [DATE]. She said she did not think it was reportable because she did not know Resident #1 had choked from the piece of chicken. The AIT said she was trained on abuse and neglect prevention and the policy for reporting prior to and after the incident. During an interview on [DATE] at 11:04 a.m., the administrator said he found out about Resident #1's possible choking on [DATE] from the AIT. The administrator said he started an investigation upon becoming aware of the incident on [DATE]. He said he told ADON B to call in LVN A and he then told the DON about the staff reporting they served the chicken and Resident #1 may have choked. He said the incident involving Resident #1 was not reported as required. He said he informed the family on [DATE]. He said when he was not in the facility the staff should have reported to the DON. The administrator said the cook had training and she should have served what was on the meal ticket. The facility Investigation Report dated [DATE] indicated the administrator was informed of the incident involving Resident #1 on [DATE] and reported to the state agency on [DATE] at 10:20 pm. During an interview on [DATE] at 9:10 a.m., the administrator said he was the Abuse Prevention Coordinator and the DON was the designee when he was not available. He said LVNs A and B were suspended on [DATE] and terminated on [DATE]. The administrator said LVN C, CNA D, DS A, and DS B were suspended on [DATE], received written warnings, and in-serviced per the facility's corrective action plan dated [DATE]. On [DATE] at 3:23 p.m., the administrator was informed that an Immediate Jeopardy was determined to have existed from [DATE] through [DATE]. The Immediate Jeopardy was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the beginning of the survey. The Immediate Jeopardy was removed on [DATE] because, prior to surveyor entrance, the facility had implemented action plans on [DATE], retrained staff from [DATE] through current, and the staff was aware of reporting and prevention measures. During an interview on [DATE] at 5:00 p.m., the administrator said he suspended the AIT, DON, ADON A, and ADON B. The facility's corrective actions taken from [DATE] and ongoing included: *In-service nursing staff on completing an incident report on all incidents identified including choking; witnessed or reported. *Incidents reports would be reviewed during clinical meeting to identify choking residents. The facility's in-services dated [DATE] indicated the following were completed: *nursing staff should prepare an incident report to document unusual and/or significant events or emergencies involving individuals or residents (including choking or strangling). *all staff were trained on the abuse/neglect policy; content included review of who was the abuse coordinator, reporting abuse and neglect immediately, and not to assume incidents were reported to the abuse coordinator. During an interview on [DATE] at 4:00 p.m. the dietary manager said there were 33 residents with mechanical soft diets.

Based on observation, interview, and record review, the facility failed to provide food prepared in a form designed to meet individual needs for 1 of 8 residents reviewed for dietary intake. (Resident #1) The facility did not serve Resident #1 a mechanical soft diet as ordered by the physician on 09/24/17 during the evening meal. The resident received a regular piece of chicken and the CNA cut the chicken into pieces. There were no licensed nursing staff available in the dining room to check the resident trays before the resident was served. Resident #1 ate the piece of chicken in the dining room and choked. The resident died shortly after. An Immediate Jeopardy was determined to have existed from 09/24/17 through 10/16/17. This was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the beginning of the survey. This failure could place 33 residents with mechanical soft diets at risk for choking and death. Findings included: Physician orders [REDACTED].#1 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His diet order dated 05/27/16 was mechanical soft with ground meats and regular thin liquids. A Dysphagia Consultation dated 05/11/17 indicated Resident #1 had a [DIAGNOSES REDACTED]. The diet recommendations indicated: mechanical soft solids, chopped, downgrade to ground as needed, and may be ground meats, but chopped vegetables if cooked soft. The Care Plans dated 06/14/17 indicated Resident #1 required staff assistance for all ADLs and required supervision with eating. The resident was on a mechanical soft diet with ground meats and regular thin liquids. A Nutrition Quarterly Progress Note dated 09/06/17 indicated Resident #1's diet was mechanical soft. An MDS dated [DATE] indicated Resident #1's BIMS was 7 (severe impairment) and required supervision when eating. During an interview on 10/19/17 at 9:05 a.m., CNA D said Resident #1 was on a mechanical soft diet with ground meat. She said Resident #1's meal ticket on his tray indicated his diet was mechanical soft with ground meat. She said when Resident #1 choked (on 09/24/17), the nurses were not in the dining room. She said she knew he should not have the chicken if it was not ground and Resident #1 said he was not supposed to have the chicken if it was not ground. CNA D said she took Resident #1's tray back to the kitchen and asked for something else. She said the kitchen staff told her to cut up the chicken. She said she went back to the table and Resident #1 asked her to take the skin off the chicken. She said she took the skin off the chicken and then cut the chicken into 5 pieces. She said she used the fork and broke up 2 of the pieces and sort of shredded the 2 pieces of chicken. She said she gave Resident #1 a spoon and went to another table to assist feeding other residents. She said she did not supervise Resident #1 at his table, but she could see Resident #1 from the other table. CNA D said she saw Resident #1 had his hand in the air and he was staring at her and pointing at his neck. She said she realized he was choking. She said she told the other aide to get the nurses. CNA D said she tried to perform the [MEDICATION NAME] manuever, but the resident was still choking. She said she realized the other nurses were not going to make it in time and told Resident #1 to raise up his feet and she pushed him down the hall. CNA D said she met LVN A and LVN C in the hall and told them Resident #1 was choking. She said she knew Resident #1 had passed before she left her shift at 10:00 p.m. on 09/24/17. CNA D said she was trained on her duties, abuse and neglect prevention and reporting, and diets and diet textures/consistencies. She said she was trained during orientation and since the incident. Nursing notes, completed by LVN A, dated 09/24/17 at 6:25 p.m. indicated nurse assistants brought Resident #1 via his wheelchair from the dining area to the nursing station. Resident #1 was assessed with [REDACTED]. The resident was assisted to his room and 3 staff assisted him from his wheelchair to his bed. The notes indicated Resident #1 had general cyanosis all over his via the assessment and signs and symptoms of [MEDICAL CONDITION] activity ceased. The head of the resident's bed was raised for respiratory support and his lower extremities were elevated for blood pressure support as well. Resident #1's skin was cool and clammy to touch and he was non-responsive to physical and verbal stimuli. The notes indicated the resident's blood pressure was not obtainable and his apical pulse was absent. Resident #1's respirations ceased and they were unable to obtain a pulse oxygen saturation reading. At 6:30 p.m., the nurse practitioner returned the call with notification of above with verbal pronouncement of death per doctor at 6:30 p.m. Notified administrator, DON, and both of the ADONs of above. During an interview on 10/19/17 at 12:53 a.m., LVN A said she was not present in the dining room when Resident #1 was served his supper meal on 09/24/17. She said she assisted another resident from the dining room at that time. She said she was coming back up the hall and 2 CNAs said Resident #1 had choked. She said Resident #1's hands were purple and he looked like he was having a [MEDICAL CONDITION]. She said there was no cyanosis. She said LVN C said he was having a [MEDICAL CONDITION]. She said he was not responsive in the hallway. LVN A said she did not ask what Resident #1 might have choked on. She said she did not talk to the aides. She said she did not perform the [MEDICATION NAME] maneuver on Resident #1 in the hallway when she first saw him. She said they took Resident #1 to his room via his wheelchair while LVN C went to check his DNR status. She said CNA M assisted Resident #1 to his bed and the resident was not responsive. LVN A said she looked in Resident #1's mouth, but didn't see anything. She said LVN B said there was a piece of chicken that looked like a piece of thread. She said she did not call the DON because she felt more comfortable calling ADON B. LVN A said she could not recall if she reported to ADON B that CNA A said Resident #1 choked. She said LVN B was assigned to the dining room on 09/24/17 and LVN B should have checked Resident #1's meal ticket. She said the nurses would alternate who went to the dining room for meal. During an interview on 10/18/17 at 3:27 p.m., LVN C said CNA A said Resident #1 choked, but he didn't look like he was choking. She said Resident #1 looked like he was having a [MEDICAL CONDITION]. She said she grabbed the crash cart and checked on Resident #1's DNR status before going to the resident's room. LVN C said Resident #1 was in bed when she arrived in the room. She said Resident #1 was not gurgling or coughing and he did not have a blue face or blue hands. She said Resident #1 was having jerking movements. She said Resident #1 did not have a history of [MEDICAL CONDITION] and was not on any [MEDICAL CONDITION] medications. LVN C said she was working as the medication nurse and was not as assigned in the dining room. On 10/19/17 at 11:58 a.m. the investigator left a message on LVN B's voicemail to return call and interview. LVN B did not respond to calls from the investigators on for an interview. A statement obtained by LVN B (obtained 10/09/17, but dated 09/24/17 -the date of the incident) indicated she was not in the dining room at the start of the incident because she was bringing trays to the residents who were not in the dining room. LVN B indicated CNA H came around the corner on Hall 200 hollering Resident #1 choked, something's wrong. LVN A, standing in the hall, called out to LVN B and LVN C and all 3 of the nurses met CNA D in the hall. LVN A went around Resident #1's wheelchair to perform the [MEDICATION NAME] maneuver on Resident #1. LVN B indicated LVN A stated I think it's a [MEDICAL CONDITION]. The statement indicated Resident #1 was sitting in the wheelchair with his hands and lower arms in his lap and his upper body was convulsing. LVN B indicated Resident #1's hands were blue, his face was pale, and his eyes were rolled back. The shaking lasted for 15-20 seconds and then the resident went limp. CNA M assisted Resident #1 to his bed then left the room. The statement indicated the nurses sat patient on side of bed to attempt [MEDICATION NAME] maneuver once again but patient was unresponsive, laid patient on back, head of bed raised The resident had no respirations and his vital signs were unable to be obtained with attempts from all 3 nurses. LVN B indicated she attempted to suction Resident #1's mouth and was unable to retrieve anything. The physician was notified and Post mortem care performed by 2 nurses. During an interview on 10/18/17 at 2:00 p.m., CNA M said he was in the hall picking up trays when CNA H ran to the nursing station. He said he went to see what was happening and saw Resident #1 bent over in his wheelchair. He said Resident #1 was not moving. He said he assisted the nurses and brought Resident #1 to his room and put him on his bed. CNA M said Resident #1 was unresponsive. He said LVN C brought the crash cart and suctioned Resident #1. He said they got out a small piece of meat that had not been chewed. CNA M said one of the nurses (he could not recall who) checked Resident #1's heart beat and it was faint. He said one of the nurses (he could not recall which one) performed the [MEDICATION NAME] maneuver on Resident #1 and then checked him again. He said he went and got a stethoscope off the nursing cart and the nurses checked Resident #1 again. CNA M said he left the resident's room and then the nurses came out of the room crying. He said he knew Resident #1 had passed. He said the nurses were supposed to be in the dining room during meal service. A statement obtained by CNA H dated 10/09/17 indicated she was a witness to Resident #1 in the dining area eating his food on 09/24/17. CNA H indicated she thought Resident #1 was choking, so she ran to tell the nurses. She indicated another aide rolled Resident #1 in his wheelchair to the nursing station and the nurses took him and proceeded with the situation. The statement indicated when the nurses came out of Resident #1's room, they said he had a [MEDICAL CONDITION] and announced he was dead. She said there were no licensed nursing staff in the dining room on 09/24/17. During an interview on 10/18/17 at 11:42 a.m., DS A said on 09/24/17 she put a chicken salad sandwich on the tray for Resident #1. She said she was aware Resident #1's diet was mechanical soft with ground meat. She said DS B took the sandwich off and told her to put a piece of chicken on the tray with mashed potatoes and peas. She said the tray was sent out to Resident #1. She said the CNA D came back to the door and said Resident #1 could not eat the chicken and DS B told her to cut it up and gave the tray back to CNA B. She said CNA D said there was no nurse in the dining room, but to start serving anyway. DS A said after the meal service she found out Resident #1 died . She said she went back into the dining room and DS B said she was sorry she told her to give Resident #1 the piece of chicken. She said the next morning on 09/25/17, she went to work and was upset about the incident involving Resident #1 and called the FSD to set up a meeting with the administrator. She said she did not tell the FSD why she wanted to have the meeting. She said the meeting never happened with the administrator and she called CNA S on 10/06/17 and asked her to set up a meeting with the AIT. She said there was a 3-way call on 10/06/17 with the AIT and she told the AIT she gave Resident #1 a piece of chicken after the direction form DS B. She said she came back to work on 10/09/17 and was told the DON wanted to speak to her. She said she told the DON that DS B told her to give Resident #1 the chicken and there were no nurses in the dining room for the meal service on 09/24/17. During an interview on 10/18/17 at 12:40 p.m., DS B said she did not recall seeing any nurses in the dining room during supper meal service. She said she told DS A to fix the chicken for Resident #1, but she did not know what was on the meal ticket. She said she was not aware Resident #1 choked. She said DS A did not say Resident #1's food was supposed to be mechanical soft. During an interview on 10/19/17 at 8:00 a.m., CNA S said on 10/06/17 she arranged a 3-way call with DS A and the AIT. She said DS A reported what happened on 09/24/17 involving Resident #1. CNA S said she was not aware of the incident until 10/06/17. She said the nurses were supposed to be in the dining room for all meals. She said the nurses were supposed to check the meal tickets prior to giving the residents their meal trays and the meal tickets were always on the trays. She said all staff were trained on abuse and neglect prevention, reporting, and resident diets. She said DS A should have reported the incident to the administrator. During an interview on 10/18/17 at 1:17 p.m., the FSD said Resident #1's diet was mechanical soft with ground meat. She said the diet cards were printed out daily and placed on the trays prior to meal services. The FSD said DS B was supposed to know what was on the trays and read the residents' meal ticket to make sure it was the correct meal. She said DS A called her and said she wanted a meeting with the administrator. She said DS A did not say why she wanted to meet with the administrator. The FSD said the meeting did not occur. She said the nurses were supposed to be in the dining room during meal service and were supposed to check the trays prior to giving the trays to the residents. She said the staff were not supposed to serve the meals out of the kitchen until the nurses were in the dining room. She said all the kitchen staff were trained on abuse and neglect prevention and reporting, diets and diet textures during orientation and since the incident. During an interview on 10/18/17 at 5:20 p.m., the dietary manager said all mechanical soft diets included ground meat. During an interview on 10/18/17 at 5:15 p.m., the DON said the nurses should have been in the dining room during meal service on 09/24/17; however, the nurses were not. She said she was informed by LVN B that she (LVN B) suctioned Resident #1 and a piece of chicken came out of his mouth. She said Resident #1 would sometimes eat in the dining room and sometimes eat at the nursing station. She said Resident #1 would eat too fast without supervision. During an interview on 10/18/17 at 10:05 a.m., ADON B said no one reported to her of Resident #1 choking on 09/24/17. She said on 09/24/17 LVN A reported Resident #1 died after a [MEDICAL CONDITION]. ADON B said the Monday or Tuesday after Resident #1 died , the DON asked her about Resident #1 choking and she told the DON that it was not reported to her that Resident #1 choked. She said she was not aware of Resident #1 choking while eating until after the AIT reported it to the administrator on 10/09/17. During an interview on 10/19/17 at 8:23 a.m., ADON A said she received a text from ADON B on 09/24/17 that Resident #1 died of natural causes. She said on 09/25/17 there were rumors that Resident #1 choked and she told the DON. She said the DON asked ADON B who said that it was reported he had a [MEDICAL CONDITION] and he had passed. She said the DON did not investigate further. She said nothing else was said about it until DS A reported to the AIT that she had served Resident #1 A piece of chicken. She said she read the chart on 09/26/17 and the charting did not match what the nurses said about [MEDICAL CONDITION] activity being confirmed by 3 LVNs. She said she did not know why 911 was not called. She said she could not understand why the LVNs would suction when they said Resident #1 had a [MEDICAL CONDITION]. She said the nurses said they did not do a [MEDICATION NAME]. She said LVN A said she suctioned but it was not in her statement. She said LVN B said the CNA said Resident #1 was choking and she went around the chair to do a [MEDICATION NAME] in the hall. She said that once the LVNs got Resident #1 in the room and on his bed a [MEDICATION NAME] was performed and nothing came out. She said LVN B said he was suctioned and nothing was removed. She said LVN C said he was suctioned and a string of chicken came out. She said she was present at LVN B's exit interview. She said LVN B admitted she suctioned a piece of un-chewed chicken and held two fingers apart and indicated approximately a 1/2 - 3/4 inch piece of chicken was suctioned out of Resident #1's mouth. She said LVN B said she suctioned Resident #1 out of curiosity. She said LVN B admitted she was not in the dining room and that she was walking trays to the residents in their rooms. She said the nurses were supposed to be in the dining room for meal service. She said Resident #1 would eat in the dining room with supervision. During an interview on 10/19/17 at 10:44 a.m., the DON said the day after the incident, on 09/25/17, ADON A came to the office and said some of the aides were arguing about what was served for supper to Resident #1. She said she asked ADON B what the staff were arguing about and ADON B said it was nothing major and she would talk to the administrator. She said ADON B came into her office on 09/25/17 and said the incident involving Resident #1 was nothing major. The DON said if she had known Resident #1 choked, she would investigated that day. She said she asked LVN A and LVN B why did they not call 911 and they responded because Resident #1 was DNR status. She said she LVN A and LVN B why an incident report was not completed for Resident #1 and they responded because it was a [MEDICAL CONDITION]. She said all the nurses said Resident #1 exhibited the signs and symptoms of [MEDICAL CONDITION]. She said she was not aware the CNAs reported to the nurses that Resident #1 choked. The DON said she was not aware Resident #1 choked on a piece of chicken until 10/09/17 when the administrator told her the dietary manager reported Resident #1 may not have had a [MEDICAL CONDITION]. During an interview on 10/19/17 at 8:46 a.m., the AIT said she became aware on 10/06/17 of the incident with Resident #1. She said CNA S called her and reported that DS A wanted to talk to her (AIT) about the food she served to Resident #1. She said DS A said it was bothering her. She said DS A said she tried to talk to her supervisor and arrange a meeting with the administrator, but the meeting had not occurred. She said DS A said she prepared Resident #1 a chicken salad sandwich and DS B told her to take away the sandwich and give him the piece of chicken. The AIT said she did not know if CNA D cut up the piece of chicken. She said she did not report the incident to the administrator until 10/09/17. She said she did not think it was reportable because she did not know Resident #1 had choked from the piece of chicken. The AIT said she was trained on abuse and neglect prevention and the policy for reporting prior to and after the incident. During an interview on 10/19/17 at 11:04 a.m., the administrator said he found out about Resident #1's possible choking on 10/09/17 from the AIT. The administrator said he started an investigation upon becoming aware of the incident on 10/09/17. He said he told ADON B to call in LVN A and he then told the DON about the staff reporting they served the chicken and Resident #1 may have choked. He said the incident involving Resident #1 was not reported as required. He said he informed the family on 10/10/17. He said when he was not in the facility the staff should have reported to the DON. The administrator said the cook had training and she should have served what was on the meal ticket. The facility Investigation Report dated 10/16/17 indicated the administrator was informed of Resident #1's incident on 10/09/17 and he reported to the state agency on 10/09/17 at 10:20 pm. During an interview on 10/18/17 at 9:10 a.m., the administrator said he was the Abuse Prevention Coordinator and the DON was the designee when he was not available. He said LVNs A and B were suspended on 10/09/17 and terminated on 10/16/17. The administrator said LVN C, CNA D, DS A, and DS B were suspended on 10/09/17, received written warnings, and in-serviced per the facility's corrective action plan dated 10/10/17. On 10/19/17 at 3:23 p.m., the administrator was informed that an Immediate Jeopardy was determined to have existed from 09/24/17 through 10/16/17. The Immediate Jeopardy was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the beginning of the survey. The Immediate Jeopardy was removed on 10/16/17 because, prior to surveyor entrance, the facility had implemented action plans on 10/09/17, retrained staff from 10/10/17 through current, and the staff was aware of reporting and prevention measures. During an interview on 10/19/17 at 5:00 p.m., the administrator said he suspended the AIT, DON, ADON A, and ADON B. The facility's action plan dated 10/10/17 included a schedule of all administration staff monitoring all meals through 11/30/17. During observations on 10/18/19 at 8:57 a.m. and 5:30 p.m. and on 10/19/17 at 7:30 a.m. and 11:30 a.m., there were nurses in the dining room for all meals, all trays were checked prior to sending to the residents, and all trays examined by the investigator had the required meal and correct texture per the meal ticket and physician orders. The facility's corrective actions taken from 10/10/17 and ongoing included: *In-service nursing staff on completing an incident report on all incidents identified including choking; witnessed or reported. *Nursing would monitor residents during meal times to ensure safety of residents. *Incidents reports would be reviewed during clinical meeting to identify choking residents. *Speech therapy to be notified of all incidents involving choking. *Interventions to be put in place to appropriately address the reason for choking and care plans updated as needed. The facility's in-services dated 10/10/17 indicated the following were completed: *nursing staff should prepare an incident report to document unusual and/or significant events or emergencies involving individuals or residents (including choking or strangling). *staff will review first aid for choking and return demonstration with proficiency check off; handout given to all employees. *all staff were trained on the abuse/neglect policy; content included review of who was the abuse coordinator, reporting abuse and neglect immediately, and not to assume incidents were reported to the abuse coordinator. The facility's in-service dated 10/12-16/17 conducted by the Dietary Services included proper diet consistencies, therapeutic diets, and liquid consistencies, proper methods of writing diet orders and how to convert diets when residents enter the facility, properly identify regular, cut up, mechanical soft and puree trays, communication with therapy on aspiration risk and/or episodes of choking/aspiration, and demonstration of properly cutting up residents' meats. The facility's in-services dated 10/16/17 indicated the following were completed: *all nurses would have CPR training updated within 30 days of 10/16/17. *staff were advised of the residents on thickened liquids and therapeutic diets and the facility's policies for thickened liquids and therapeutic diets. *nurses would complete communication forms only if there was a physician order [REDACTED]. Nurses would attach a copy of the diet changes or new diet order to the communication form prior to delivering to dietary. Nurses were to include all three parts when writing/clarifying diet orders: 1. Therapeutic Diet, 2. Solid Texture (regular, mechanical soft with ground, puree), and 3. Liquid Texture. *the process for nurses to write diet orders. During an interview on 10/19/17 at 4:00 p.m. the dietary manager said there were 33 residents with mechanical soft diets.

Based on interview and record review, the facility failed to ensure all alleged violations of neglect were reported immediately to the administrator and state agency in accordance with state law and failed to have evidence of the alleged violation was thoroughly investigated for 1 of 10 residents reviewed for neglect. (Resident #1) The facility did not report an incident immediately to the administrator when Resident #1 choked when he was served the wrong diet order on [DATE] during the evening meal. Resident #1 died shortly after. The DON was informed on [DATE] the resident died after having [MEDICAL CONDITION] activity and there were rumors of the resident choking during the meal service. The AIT was made aware of the incident on [DATE] by another staff. The facility did not investigate the incident until the administrator became aware of Resident #1 choking to death until [DATE]. An Immediate Jeopardy was determined to have existed from [DATE] through [DATE]. This was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the beginning of the survey. This failure could place 33 residents with mechanical soft diets at risk for choking and death. Findings included: Physician orders [REDACTED].#1 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His diet order dated [DATE] was mechanical soft with ground meats and regular thin liquids. A Dysphagia Consultation dated [DATE] indicated Resident #1 had a [DIAGNOSES REDACTED]. The diet recommendations indicated: mechanical soft solids, chopped, downgrade to ground as needed, and may be ground meats, but chopped vegetables if cooked soft. The Care Plans dated [DATE] indicated Resident #1 required staff assistance for all ADLs and required supervision with eating. The resident was on a mechanical soft diet with ground meats and regular thin liquids. A Nutrition Quarterly Progress Note dated [DATE] indicated Resident #1's diet was mechanical soft. An MDS dated [DATE] indicated Resident #1's BIMS was 7 (severe impairment) and required supervision when eating. During an interview on [DATE] at 9:05 a.m., CNA D said Resident #1 was on a mechanical soft diet with ground meat. She said Resident #1's meal ticket on his tray indicated his diet was mechanical soft with ground meat. She said when Resident #1 choked (on [DATE]), the nurses were not in the dining room. She said she knew he should not have the chicken if it was not ground and Resident #1 said he was not supposed to have the chicken if it was not ground. CNA D said she took Resident #1's tray back to the kitchen and asked for something else. She said the kitchen staff told her to cut up the chicken. She said she went back to the table and Resident #1 asked her to take the skin off the chicken. She said she took the skin off the chicken and then cut the chicken into 5 pieces. She said she used the fork and broke up 2 of the pieces and sort of shredded the 2 pieces of chicken. She said she gave Resident #1 a spoon and went to another table to assist feeding other residents. She said she could see Resident #1 from the other table. CNA D said she saw Resident #1 had his hand in the air and he was staring at her and pointing at his neck. She said she realized he was choking. She said she told the other aide to get the nurses and attempted to perform the [MEDICATION NAME] maneuver without success. She said she realized the other nurses were not going to make it in time and told Resident #1 to raise up his feet and she pushed him down the hall. CNA D said she met LVN A and LVN C in the hall and told them Resident #1 was choking. She said she knew Resident #1 had passed before she left her shift at 10:00 p.m. on [DATE]. CNA D said she was trained on her duties, abuse and neglect prevention and reporting, and diets and diet textures/consistencies during orientation and since the incident. Nursing notes, completed by LVN A, dated [DATE] at 6:25 p.m. indicated nurse assistants brought Resident #1 via his wheelchair from the dining area to the nursing station. Resident #1 was assessed with [REDACTED]. The resident was assisted to his room and 3 staff assisted him from his wheelchair to his bed. The notes indicated Resident #1 had general cyanosis all over his via the assessment and signs and symptoms of [MEDICAL CONDITION] activity ceased. Resident #1's skin was cool and clammy to touch and he was non-responsive to physical and verbal stimuli. The notes indicated the resident's blood pressure was not obtainable and his apical pulse was absent. Resident #1's respirations ceased and they were unable to obtain a pulse oxygen saturation reading. At 6:30 p.m., the nurse practitioner returned the call with notification of above with verbal pronouncement of death per doctor at 6:30 p.m. Notified Administrator, DON, and both of the ADONs of above. During an interview on [DATE] at 12:53 a.m., LVN A said she was not present in the dining room when Resident #1 was served his supper meal on [DATE]. She said she was coming back up the hall and 2 CNAs said Resident #1 had choked. She said Resident #1's hands were purple and he looked like he was having a [MEDICAL CONDITION]. She said LVN C said he was having a [MEDICAL CONDITION]. She said they took Resident #1 to his room via his wheelchair while LVN C went to check his DNR status. She said CNA M assisted Resident #1 to his bed and the resident was not responsive. LVN A said she looked in Resident #1's mouth, but didn't see anything. She said LVN B said there was a piece of chicken that looked like a piece of thread. She said she did not call the DON because she felt more comfortable calling ADON B. LVN A said she could not recall if she reported to ADON B that CNA A said Resident #1 choked. During an interview on [DATE] at 3:27 p.m., LVN C said CNA A said Resident #1 choked, but he didn't look like he was choking. She said Resident #1 looked like he was having a [MEDICAL CONDITION]. She said Resident #1 was having jerking movements. She said Resident #1 did not have a history of [MEDICAL CONDITION]. LVN C said she was working as the medication nurse and was not as assigned in the dining room. On [DATE] at 11:58 a.m. the investigator left a message on LVN B's voicemail to return call and interview. LVN B did not respond to calls from the investigators on for an interview. A statement obtained by LVN B (obtained [DATE], but dated [DATE] -the date of the incident) indicated she was not in the dining room at the start of the incident. LVN B indicated CNA H came around the corner on Hall 200 hollering Resident #1 choked, something's wrong. LVN A, standing in the hall, called out to LVN B and LVN C and all 3 of the nurses met CNA D in the hall. LVN A went around Resident #1's wheelchair to perform the [MEDICATION NAME] maneuver on Resident #1. LVN B indicated LVN A stated I think it's a [MEDICAL CONDITION]. The statement indicated Resident #1 was sitting in the wheelchair with his hands and lower arms in his lap and his upper body was convulsing. LVN B indicated Resident #1's hands were blue, his face was pale, and his eyes were rolled back. The shaking lasted for ,[DATE] seconds and then the resident went limp. CNA M assisted Resident #1 to his bed then left the room. The statement indicated the nurses sat patient on side of bed to attempt [MEDICATION NAME] maneuver once again but patient was unresponsive, laid patient on back, head of bed raised The resident had no respirations and his vital signs were unable to be obtained with attempts from all 3 nurses. LVN B indicated she attempted to suction Resident #1's mouth and was unable to retrieve anything. The physician was notified and Post mortem care performed by 2 nurses. During an interview on [DATE] at 2:00 p.m., CNA M said he was in the hall picking up trays when CNA H ran to the nursing station. He said he went to see what was happening and saw Resident #1 bent over in his wheelchair. He said Resident #1 was not moving. He said he assisted the nurses and brought Resident #1 to his room and put him on his bed. CNA M said Resident #1 was unresponsive. He said LVN C brought the crash cart and suctioned Resident #1. He said they got out a small piece of meat that had not been chewed. CNA M said he left the resident's room and then the nurses came out of the room crying. He said he knew Resident #1 had passed. A statement obtained by CNA H dated [DATE] indicated she was a witness to Resident #1 in the dining area eating his food on [DATE]. CNA H indicated she thought Resident #1 was choking, so she ran to tell the nurses. She indicated another aide rolled Resident #1 in his wheelchair to the nursing station and the nurses took him and proceeded with the situation. The statement indicated when the nurses came out of Resident #1's room, they said he had a [MEDICAL CONDITION] and announced he was dead. During an interview on [DATE] at 11:42 a.m., DS A said on [DATE] she put a chicken salad sandwich on the tray for Resident #1. She said she was aware Resident #1's diet was mechanical soft with ground meat. She said DS B took the sandwich off and told her to put a piece of chicken on the tray with mashed potatoes and peas. She said CNA D said there was no nurse in the dining room, but to start serving anyway. DS A said after the meal service she found out Resident #1 died . She said the next morning on [DATE], she went to work and was upset about the incident involving Resident #1 and called the FSD to set up a meeting with the administrator. She said she did not tell the FSD why she wanted to have the meeting. She said the meeting never happened with the administrator and she called CNA S on [DATE] and asked her to set up a meeting with the AIT. She said there was a 3-way call on [DATE] with the AIT and she told the AIT she gave Resident #1 a piece of chicken after the direction form DS B. She said she came back to work on [DATE] and was told the DON wanted to speak to her. She said she told the DON Resident #1 was given the incorrect texture for his chicken and he choked on it. During an interview on [DATE] at 8:00 a.m., CNA S said on [DATE] she arranged a 3-way call with DS A and the AIT and DS A reported what happened on [DATE] involving Resident #1. CNA S said she was not aware of the incident until [DATE]. She said all staff were trained on abuse and neglect prevention, reporting, and resident diets. She said DS A should have reported the incident to the administrator. During an interview on [DATE] at 1:17 p.m., the FSD said DS A called her and said she wanted a meeting with the administrator. She said DS A did not say why she wanted to meet with the administrator. The FSD said the meeting did not occur. She said all the kitchen staff were trained on abuse and neglect prevention and reporting, diets and diet textures during orientation and since the incident. During an interview on [DATE] at 10:05 a.m., ADON B said no one reported to her of Resident #1 choking on [DATE]. She said on [DATE] LVN A reported Resident #1 died after a [MEDICAL CONDITION]. ADON B said the Monday or Tuesday after Resident #1 died , the DON asked her about Resident #1 choking and she told the DON that it was not reported to her that Resident #1 choked. She said she was not aware of Resident #1 choking while eating until after the AIT reported it to the administrator on [DATE]. During an interview on [DATE] at 8:23 a.m., ADON A said she received a text from ADON B on [DATE] that Resident #1 died of natural causes. She said on [DATE] there were rumors that Resident #1 choked and she told the DON. She said the DON asked ADON B who said that it was reported he had a [MEDICAL CONDITION] and he had passed. She said the DON did not investigate any further. She said nothing else was said about it until DS A reported to the AIT that she had served Resident #1 a piece of chicken. She said she read the chart on [DATE] and the charting did not match what the nurses said about [MEDICAL CONDITION] activity being confirmed by 3 LVNs. She said she did not know why 911 was not called. She said LVN A said she suctioned the resident, but it was not in her statement. She said LVN B said the CNA said Resident #1 was choking and she went around the chair to perform the [MEDICATION NAME] maneuver in the hall. ADON A said LVN B said he was suctioned and nothing was removed. She said LVN C said Resident #1 was suctioned and a string of chicken came out. She said she was present at LVN B's exit interview. She said LVN B admitted she suctioned a piece of chicken and held two fingers apart and indicated approximately a ,[DATE] - ,[DATE] inch piece of chicken was suctioned out of Resident #1's mouth. During an interview on [DATE] at 10:44 a.m., the DON said the day after the incident, on [DATE], ADON A came to the office and said some of the aides were arguing about what was served for supper to Resident #1. She said she asked ADON B what the staff were arguing about and ADON B said it was nothing major and she would talk to the administrator. She said ADON B came into her office on [DATE] and said the incident involving Resident #1 was nothing major. The DON said if she had known Resident #1 choked, she would investigated that day. She said she asked LVN A and LVN B why did they not call 911 and they responded because Resident #1 was DNR status. She said she LVN A and LVN B why an incident report was not completed for Resident #1 and they responded because it was a [MEDICAL CONDITION]. She said all the nurses said Resident #1 exhibited the signs and symptoms of [MEDICAL CONDITION]. She said she was not aware the CNAs reported to the nurses that Resident #1 choked. The DON said she was not aware Resident #1 choked on a piece of chicken until [DATE] when the administrator told her the dietary manager reported Resident #1 may not have had a [MEDICAL CONDITION]. During an interview on [DATE] at 8:46 a.m., the AIT said she became aware on [DATE] of the incident with Resident #1. She said CNA S called her and reported that DS A wanted to talk to her (AIT) about the food she served to Resident #1. She said DS A said it was bothering her. She said DS A said she tried to talk to her supervisor and arrange a meeting with the administrator, but the meeting had not occurred. The AIT said DS A said she prepared Resident #1 a chicken salad sandwich and DS B told her to take away the sandwich and give him the piece of chicken. She said she did not report the incident to the administrator until [DATE]. She said she did not think it was reportable because she did not know Resident #1 had choked from the piece of chicken. The AIT said she was trained on abuse and neglect prevention and the policy for reporting prior to and after the incident. During an interview on [DATE] at 11:04 a.m., the administrator said he found out about Resident #1's possible choking on [DATE] from the AIT. The administrator said he started an investigation upon becoming aware of the incident on [DATE]. He said he told ADON B to call in LVN A and he then told the DON about the staff reporting they served the chicken and Resident #1 may have choked. He said the incident involving Resident #1 was not reported as required. He said he informed the family on [DATE]. He said when he was not in the facility the staff should have reported to the DON. The administrator said the cook had training and she should have served what was on the meal ticket. The facility Investigation Report dated [DATE] indicated the administrator was informed of the incident involving Resident #1 on [DATE] and reported to the state agency on [DATE] at 10:20 pm. During an interview on [DATE] at 9:10 a.m., the administrator said he was the Abuse Prevention Coordinator and the DON was the designee when he was not available. He said LVNs A and B were suspended on [DATE] and terminated on [DATE]. The administrator said LVN C, CNA D, DS A, and DS B were suspended on [DATE], received written warnings, and in-serviced per the facility's corrective action plan dated [DATE]. The facility's undated Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents indicated Each resident has the right to be free from .neglect . On [DATE] at 3:23 p.m., the administrator was informed that an Immediate Jeopardy was determined to have existed from [DATE] through [DATE]. The Immediate Jeopardy was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the beginning of the survey. The Immediate Jeopardy was removed on [DATE] because, prior to surveyor entrance, the facility had implemented action plans on [DATE], retrained staff from [DATE] through current, and the staff was aware of reporting and prevention measures. During an interview on [DATE] at 5:00 p.m., the administrator said he suspended the AIT, DON, ADON A, and ADON B. The facility's corrective actions taken from [DATE] and ongoing included: *In-service nursing staff on completing an incident report on all incidents identified including choking; witnessed or reported. *Incidents reports would be reviewed during clinical meeting to identify choking residents. The facility's in-services dated [DATE] indicated the following were completed: *nursing staff should prepare an incident report to document unusual and/or significant events or emergencies involving individuals or residents (including choking or strangling). *all staff were trained on the abuse/neglect policy; content included review of who was the abuse coordinator, reporting abuse and neglect immediately, and not to assume incidents were reported to the abuse coordinator. During an interview on [DATE] at 4:00 p.m. the dietary manager said there were 33 residents with mechanical soft diets.